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Based on observation, interview and record review the facility failed to ensure the Condition of Participation (CoP) for Governing Body, was met as evidenced by:

1.The facility's governing body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to provide oversight to ensure intravenous (IV, administered into a vein) titratable (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) medications were administered in a safe manner when:

1.a. Orders were not discontinued per physician order by healthcare team members for five of 41 sampled patients (Patient 1, 6, 7, 26 and 27), in accordance with the facility's policy and procedure regarding IV titration medications. Patient 1 and Patient 27 received IV nicardipine (medication to treat high blood pressure) four (4) days and 26 hours and 50 minutes from last administration, respectively. Patient 6's IV Norepinephrine (medication to raise blood pressure) and IV Nicardipine, were not discontinued on 5/16/2025 and 5/19/2025, respectively. Patient 7's Nicardipine drip was not discontinued on 5/26/2025. Patient 26 received IV Propofol infusion (an intravenous medication used for sedation) 39 hours and 50 minutes beyond the last administration date of 5/27/2025.

This deficient practice enabled nursing staff to gain access to discontinued medications and administered without physician order. Patient 1 suffered hypotension (low blood pressure) after IV nicardipine (medication to treat high blood pressure) administration. This deficient practice also had the potential to result in putting Patients 6, 7, 26, 27 and other patients, receiving IV titratable medications, at risk for adverse effects such as severe hypotension, excessive sedation (drowsiness or sleep), respiratory depression (a breathing disorder characterized by slow or shallow breathing that doesn't allow for proper gas exchange in the lungs) and/or death, when the medications were given without valid physician order. (Refer to A-0063)

1.b. There was no parameter range (specific instructions or guidelines to determine the correct administration of a drug) set in the IV titratable medication order (Order set for Nicardipine drip) for one of 41 sampled patients (Patient 6), in accordance with the facility's policy regarding "Titratable Medication Infusion Administration."

This deficient practice had the potential to put Patient 6 and other patients to receive unnecessary medications, which can compromise patient safety due to adverse medication effects such as severe hypotension. (Refer to A-0063)

2. The facility's Governing Body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision making,) failed to ensure patient care and services rendered under contract with an outside entity (Radiology Services, provide imaging technology to diagnose and treat medical conditions. Radiologists, who are medical doctors specializing in radiology, interpret these images to aid in diagnosis and treatment planning), adhered to Radiology contract service expectations for timely (in less than 30 minutes) computed tomography (CT scan, medical imaging creates detailed images of the inside of the body) interpretation for one of five sampled patients (Patient 4) in the Emergency Department (ED), in accordance with the facility's policy regarding contract processing and service agreement.

This deficient practice resulted in a delay in 2-hours and 24-minutes in the interpretation of Patient 4's CT of the brain, which delayed potentially life-saving intervention and contributed to a high likelihood of irreversible neurological damage (injury or harm that affects the brain, spinal cord [a bundle of nerves running down the spine]). Additionally, this deficient practice had the potential to cause delays in care for other patients presenting to the emergency department (ED) who require emergent CT interpretation for time-sensitive conditions. (Refer to A-0083)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on interview and record review the facility failed to ensure the Condition of Participation for Patient Rights, was met as evidenced by:

1. The facility failed to protect one of 19 sampled patients (Patient 3) in the Psychiatric (relating to mental illness) Acute Care (PAC) unit, from an assault (an act that threatens physical harm to a person, whether or not actual harm is done), in accordance with the facility's protocol regarding provision of a safe environment of care, when Patient 2 entered Patient 3's room for approximately 2 to 3 minutes, with no staff members present in the hallway while Patient 2 entered Patient 3's room.

This deficient practice resulted in Patient 2 (male patient) entering Patient 3's room, resulting in scratches to Patient 3's (female patient) upper and lower lip and had the potential to result in serious injury or harm. In addition, after the incident, Patient 3 became anxious, watchful, fearful, scared, and constantly looking over her shoulder. (Refer to A-0145)

2. The facility failed to ensure one of two (2) sampled Behavioral Health Unit (BHU, a specialized area within a hospital dedicated to providing mental health care) staff (Licensed Vocational Nurse 2), completed her "Abuse and Neglect" module (training module that discusses the types of abuse [refers to any action or failure to act by a caregiver that causes harm or distress to a patient, encompassing various forms like physical, emotional, sexual, and financial abuse, as well as neglect] and neglect, the related indicators and the reporting responsibilities of health care providers) yearly, in accordance with the facility's annual education requirements.

This deficient practice had the potential for violations of patient rights such as being free from all forms of abuse, due to lack of staff training. (Refer to A-0145)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on interview and record review the facility failed to ensure the Condition of Participation for Quality Assurance and Performance Improvement (QAPI), was met as evidenced by:

1. The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI, a data-driven, facility-wide program designed to monitor, assess, and improve the quality and safety of patient care) program included monitoring and oversight of services provided under contract, specifically radiology services (provide imaging technology to diagnose and treat medical conditions. Radiologists, who are medical doctors specializing in radiology, interpret these images to aid in diagnosis and treatment planning), to ensure timely (in less than 30 minutes) computed tomography (CT scan, medical imaging creates detailed images of the inside of the body) interpretation for one of five sampled patients (Patient 4) in the Emergency Department (ED), in accordance with the facility's performance improvement policy. Additionally, the hospital failed to establish an ongoing process to measure, analyze, and track performance indicators related to contracted radiology services, as required, to support and improve health outcomes and quality of care.

This deficient practice resulted in the lack of timely identification and response to performance issues that directly affected patient care, including delays in emergency CT interpretation for Patient 4. This deficient practice had the potential for delays in the delivery of necessary care interventions for Patient 4 and other patients in the facility. (Refer to A-0273)

2. The facility's Quality Assurance and Performance Improvement (QAPI, a data-driven, facility-wide program designed to monitor, assess, and improve the quality and safety of patient care) committee failed to Analyze and track an adverse patient event (any unfavorable or unintended occurrence), in accordance with the facility's policy regarding performance improvement, when it failed to conduct a thorough investigation for an allegation of an assault (an act that threatens physical harm to a person, whether or not actual harm is done) that was reported by one of 41 sampled patients (Patient 3) on 5/7/2025, when Patient 2 entered Patient 3's room and covered Patient 3's mouth, which resulted to visible scratches to Patient 3's upper and lower lip. In addition, the facility failed to report the incident to the regulatory agency within 24 hours of the incident, in accordance with the facility's policy regarding adverse event reporting.

This deficient practice led to an incomplete investigation of the alleged assault on Patient 3 by Patient 2 and resulted in the facility not reporting the assault within 24 hours to the regulatory agency resulting in a delay of investigation of the incident. This deficient practice of not analyzing and tracking adverse patient events also had the potential for the facility's inability to adequately identify and address issues, leading to an increased risk of preventable harm to patients. (Refer to A-0286)

3. The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) team performed a thorough investigation for one of 41 sampled patient's (Patient 1) medication safety event on 2/6/2025 (Patient 1 was re-started on a Nicardipine drip [medication to treat high blood pressure] without a proper physician order which caused a sudden drop in Patient 1's blood pressure) and identify a systemic failure regarding IV titratable medication order discontinuation, in order to prevent two other patients (Patient 26 and 27) from receiving an IV titratable medication that should have been discontinued, in accordance with the facility's policies regarding performance improvement and IV titratable medications.

This deficient practice, regarding the lack of a thorough investigation into Patient 1's medication safety event, resulted in no action plan implemented to ensure IV titratable medications were discontinued per physician orders, thus leading to other incidents involving other patients (Patient 26 and Patient 27) receiving IV titration medications, which should have been discontinued 23 hours after the last administration, as well as putting patients at risk for harm and potential to experience complications. (Refer to A-0286)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on interview and record review the facility failed to ensure the Condition of Participation for Nursing Services, was met as evidenced by:

1. The facility failed to ensure that for one of 41 sampled patients (Patient 27), nursing staff alternated the peripheral intravenous site (PIV, a small, short, flexible tube [catheter] inserted into a vein, usually in the hand or arm, to administer fluids, medications, or blood products), every 12 hours during continuous infusion of nicardipine (Cardene IV, a medication to treat chest pain or high blood pressure [BP]), through a catheter or needle that is continuously delivering the substance into the body, in accordance with the physician order.

This deficient practice had the potential for Patient 27 to develop complications associated with Nicardipine IV administration such as phlebitis (an inflammation of a vein), infiltration (when some of the fluid leaks out into the tissues under the skin where the tube has been put into the vein), or extravasation (the leakage of fluid or substances from a blood vessel or other enclosed space into the surrounding tissues, resulting in pain, swelling), which may go unrecognized and untreated, leading to tissue damage or necrosis (tissue death) and worsening of Patient 27's condition. (Refer to A-0395)

2. The facility failed to ensure for one of 41 sampled patients (Patient 13), a Clinical Institute Withdrawal Assessment for Alcohol (CIWA, is a tool used to assess the severity of alcohol withdrawal symptoms) assessment was completed and documented per facility's policy regarding "Inpatient Management of Alcohol Withdrawal (a range of symptoms that can happen if someone stops or significantly reduce alcohol intake after long-term use)."

This deficient practice had the potential for delayed recognition of a patient's withdrawal symptoms (example: increased blood pressure, increased heart rate, and tremor [shakiness] of hands or other body parts), potentially resulting in inappropriate or insufficient treatment for Patient 13. (Refer to A-0395)

3. The facility failed to formulate an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 41 sampled patients (Patient 26), to address Patient 26's admitting diagnosis of seizures (a sudden, temporary disturbance of the brain's normal electrical activity, often manifesting as changes in muscle tone, behavior, or awareness), in accordance with the facility's policy regarding care plans.

This deficient practice had the potential for Patient 26's care needs not to be met when no implementation of individualized care plan for seizures and safety precautions were embedded into Patient 26's treatment and care plan, which could result in complications such aspiration (the accidental inhalation of foreign materials, such as food, liquid, or stomach contents, into the lungs instead of the digestive tract [the mouth, stomach, and intestines]) leading to breathing problems , prolonged hospitalization, and/or even death. (Refer to A-0396)

4. The facility failed to ensure one of 41 sampled patient's (Patient 13) plan of care regarding aspiration precaution (measures taken to prevent the accidental inhalation of food, liquid, or other substances into the lungs. These precautions are especially important for individuals with swallowing difficulties or other conditions that increase their risk of aspiration), was developed and implemented upon admission (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility's policy regarding care plans.

This deficient practice had the potential for serious complications such as aspiration pneumonia (lung infection that can be particularly dangerous for individuals with weakened immune systems or underlying health conditions), respiratory distress (difficulty breathing), prolonged hospitalization, and/or death. (Refer to A-0396)

5. The facility failed to ensure one of 41 sampled patient's (Patient 20) plan of care regarding Chest Pain (often related to heart disease, its symptoms due to a heart attack or other heart condition includes Pressure, tightness, pain, squeezing or aching in the chest), was developed and implemented upon admission (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility's policy regarding care plans

This deficient practice had the potential to result in Patient 20's care needs and risks to not be identified and addressed in a timely manner, which may result in complications such as heart failure (a condition where the heart cannot pump enough blood to meet the body's needs), cardiac arrest (when the heart stops beating), and/or death. (Refer to A-0396)

6. The facility failed to ensure one of 41 sampled patient's (Patient 22) plan of care regarding Fluid and Electrolyte Imbalance (maintaining a stable internal environment by regulating the amount of fluids and electrolytes [charged molecules] in the body. This balance is crucial for various bodily functions, including nerve and muscle activity, and blood pressure regulation), was developed and implemented upon admission (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility's policy regarding care plans.

This deficient practice had the potential for Patient 22's care needs and risks to not be identified and addressed in a timely manner which may result in complications such as dehydration (a condition that occurs when your body doesn't have enough fluid to function properly. It happens when you lose more fluids than you take in, which can disrupt various bodily functions like maintaining body temperature, transporting nutrients, and eliminating waste), prolonged recovery, and/or death. (Refer to A-0396)

7. The facility failed to ensure that one of 41 sampled patients (Patient 26), had the RASS (the Richmond Agitation Sedation Scale, is a tool designed to assess the level of alertness and agitated behavior in critically ill patients) documented during the initiation of Precedex infusion (dexmedetomidine, a sedative medication used for sedation in intensive care patients), in accordance with the facility's policy regarding titratable medications administration (the administration of a medication over time, starting with the least dosage required for improving the medical condition).

This deficient practice had the potential for Patient 26 to experience inadequate sedation (drowsiness or sleep) management, including over-sedation or under-sedation, which could lead to increased risk of adverse events such as delayed neurological assessment, respiratory depression (inadequate ventilation, causing a low breathing rate), and unrecognized agitation (a state of extreme restlessness or uneasiness), thereby compromising Patient 26's safety. (Refer to A-0398)

8. The facility failed to monitor nineteen (19) of 19 sampled patients (Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39) in the Psychiatric (relating to mental or behavior illness) Acute Care (PAC) unit, every 15 minutes, in accordance with the facility's policy and procedure regarding managing patients with high risk behaviors (actions that significantly increase the potential for harm, injury, or negative consequences, impacting both the individual and potentially others) who are admitted to the Behavioral Health Unit (or PAC unit).

This deficient practice placed 19 patients' safety at risk such as self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence. (Refer to A-0398)

9. The facility failed to ensure its nursing staff communicated and reported critical test results (a test or examination that always requires rapid communication of the results) for one of 41 sampled patients (Patient 1), in accordance with the facility's policy and procedure regarding critical test result reporting, when there was no evidence that Patient 1's CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) scans were reported to a physician within required timeframe (within 60 minutes) on 2/6/2025.

This deficient practice had the potential to delay for Patient 1's physician to evaluate Patient 1's condition and determine appropriate interventions. (Refer to A-0398)

10. The facility failed to ensure its nursing staff performed a National Institute of Health Stroke Scale (NIHSS, a clinical assessment tool used to measure a patient's neurological status after a stroke to quantify the severity of stroke-related deficits and monitor changes in a patient's condition over time) assessment, when Stroke Alert (a protocol the facility developed in response to patient experiencing acute [new onset] stroke symptoms) was activated for one of 41 sampled patients (Patient 1) on 2/6/2025, in accordance with the facility's policy and procedure regarding r stroke protocol.

This deficient practice resulted in Patient 1's severity of stroke not evaluated at the time when stroke alert was called, and had the potential to result in delayed g identification and reporting of the severity of stroke Patient 1 was experiencing, to the physician and the stroke team, thus causing delay in care and treatment. (Refer to A-0398)

11. The facility failed to ensure its nursing staff adhered to physician order and facility's policy and procedure regarding intravenous (IV, administered into a vein) titratable (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) medications when Nursing staff administered and titrated IV nicardipine (medication to treat high blood pressure) without proper titration (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) and blood pressure (BP, normal blood pressure is generally considered to be less than 120/80 mmHg [millimeters of mercury, unit of measure]) monitoring for two of 41 sampled patients (Patient 1 and Patient 4).

This deficient practice resulted in Patient 1's blood pressure (BP) drop from 222/116millimeters of mercury (mmHg, unit of measure) to 67/40 mmHg within 1 hour and 30 minutes (from 6 p.m. to 7:30 p.m.), compromising Patient 1's perfusion (process of blood carrying oxygen and nutrients to the body tissues and organs) to the brain. This deficient practice also had the potential to put Patient 4 at risk for hypotension (low blood pressure). (Refer to A-0405)

12. The facility failed to discontinue the nicardipine (Cardine IV infusion, a medication to control blood pressure and prevent cerebral [brain] venous spasm) and obtain a new physician order to restart Nicardipine IV infusion for one of 41 sampled patients (Patient 27), when Nicardipine IV was restarted beyond the 23 hours of its last administration (the order should have been discontinued and deemed inactive), in accordance with the original physician order set and the facility's policy regarding titratable medications (slowly increasing the dose of a medicine by very small amounts over time [minutes, hours, days, weeks]).

This deficient practice resulted in inappropriate administration of nicardipine to Patient 27 (beyond the prescribed duration), placing Patient 27 at increased risk of harm such as severe hypotension (low blood pressure) thus compromising Patient 27's safety. (Refer to A-0405)

13. The facility failed to discontinue propofol (a medication used for general anesthesia induction and maintenance, sedation during monitored anesthesia care, and sedation) and obtain a new physician order to restart propofol infusion for one of 41 sampled patients (Patient 26), when propofol was continued beyond the 23 hours of its last administration, in accordance with the original physician order set and the facility's policy regarding titratable medications (slowly increasing the dose of a medicine by very small amounts over time [minutes, hours, days, weeks).

This deficient practice resulted in inappropriate administration of propofol to Patient 26 (beyond the prescribed duration), placing Patient 26 at increased risk of harm such as excessive sedation (drowsiness or sleep), respiratory depression (a breathing disorder characterized by slow or shallow breathing that doesn't allow for proper gas exchange in the lungs) and/or death. (Refer to A-0405)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Medical Record Services, was met as evidenced by:

1.The facility failed to ensure that medical records for 20 of 41 sampled patients (Patients 2, 3, 8, 9, 10, 11, 12, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39) were accurately written or documented, in accordance with the facility's policies regarding medical record content and completeness, when:

1.a. The rounds (a systematic process where a healthcare team member checks on a patient regularly) conducted, every 15 minutes, in the East side of the Psychiatric (relating to mental illness) Acute Care unit, were inaccurately documented in the medical record for 19 of 19 patients (Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39).

This deficient practice led to the inaccurate documentation on 5/7/2025 at 4:15 a.m., that 19 patients had been visualized by a staff, when in fact, the round was not conducted at that time. This deficient practice also placed 19 patients' safety at risk such as self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence. (Refer to A-0438)

1.b. For Patient 27, the electronic medical record (eMR, digital version of paper chart) titled, "Medication Administration Record (MAR)," did not accurately reflect the documentation of the peripheral intravenous line (PIV, a short, flexible plastic tube [catheter] inserted into a vein for the purpose of administering fluids, medications, or blood products) used to administer nicardipine (a medication used to treat hypertension [high blood pressure, a condition where the force of blood pushing against the walls of the arteries is consistently too high]).

This deficient practice had the potential for Patient 27's PIV site to be inadequately monitored for complications such as infiltration (the inadvertent delivery of fluid or medication into surrounding tissue that has the potential to harm the patient), phlebitis (inflammation of the vein), or extravasation (the leakage of fluid or substances from a blood vessel or other enclosed space into the surrounding tissues), leading to tissue damage, tissue ischemia (blood flow to a tissue or organ is restricted or reduced) , or necrosis (death of the tissue), and if undetected, may result in delayed treatment and/or negative health outcomes for Patient 27. (Refer to A-0438)

2. The facility failed to ensure that for one of 41 sampled patients (Patient 5), a death note (a documented record in the medical record to indicate the patient's death, including the cause and circumstances), was completed and filed in Patient 5's electronic medical record (eMR, digital version of paper charting) to formally document and record the death of a patient (Patient 5), in accordance with the facility's policy regarding medical record content and completeness.

This deficient practice violated Patient 5's rights (the legal protections and ethical considerations that ensure individuals receive respectful, equitable, and informed medical care) with regards to the completeness and integrity of the medical record, potentially damaging a patient's and their family's trust in the healthcare system and their providers. (Refer to A-0450)

3. The facility failed to ensure that for one of 41 sampled patients (Patient 24), a comprehensive medical history and physical examination (H&P, a formal assessment of a patient that includes gathering their medical history and performing a physical examination) was completed, documented, and filed within 24 hours of Patient 24's admission and prior to surgery, in accordance with the facility's policy regarding chart completeness.

This deficient practice had the potential to compromise Patient 24's safety by delaying the identification of underlying health issues, contraindication, or risks that could impact surgical outcomes. In addition, this deficient practice can lead to inappropriate delayed medical interventions for Patient 24, increased risk of perioperative complications, and adverse events, or harm to the patient (Patient 24) due insufficient baseline assessment and incomplete documentation. (Refer to A-0458)

4. The facility failed to ensure that for one of 41 sampled patients (Patient 23), a completed verified informed consent (a voluntary formal confirmation- agreement signed by the patient or their authorized representative that confirms they understand the nature, risks, benefits, and alternatives of a medical procedure before it is performed) for anesthesia (blocking pain signals to the brain, preventing a person from feeling pain during a procedure), was filled out indicating the type of anesthesia to be used during the procedure (laminectomy, a surgical procedure where a surgeon removes a portion of the lamina, which is the back part of the vertebra, to relieve pressure on the spinal cord or nerve roots), initials, date, time and witness signature in the area designated for anesthesia on the consent form, in accordance with the facility's policy regarding consents.

This deficient practice had the potential to negatively affect Patient 23's rights to decision-making (refers to the process in which patients are actively engaged in making informed choices about their healthcare options), undermining Patient 23's autonomy (person's right to make their own decisions) and compromise the legal validity (refers to legitimacy and enforceability of a document) of the consent due to lack of completeness of the medical record (verified informed consent form). (Refer to A-0466)

5. The facility failed to ensure that for one of 41 sampled patients (Patient 26), nursing staff initiated, maintained, and documented a current nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for status epilepticus (a seizure [a sudden, temporary disturbance of the brain's normal electrical activity, often manifesting as changes in muscle tone, behavior, or awareness] lasting longer than five minutes or recurrent seizures without regaining full consciousness between them) that reflected the patient's (Patient 26's) goals and the nursing care to be provided to meet Patient 26's needs, in accordance with the facility's policy regarding care plans.

This deficient practice had the potential for Patient 26's care needs not to be met leading to adverse health outcomes for Patient 26, such as increased risk for injury during seizures, delayed recognition and response to seizure activity, lack of safety precautions to minimize the risk of harm during seizures. In addition, the lack of documented implementation of a seizure care plan had the potential to compromise communication among healthcare providers leading to disruptions in the continuity of care and Patient 26's safety. (Refer to A-0467)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on interview and record review, the facility's governing body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to provide oversight to ensure intravenous (IV, administered into a vein) titratable (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) medications were administered in a safe manner when:

1. Orders were not discontinued per physician order by healthcare team members for five of 41 sampled patients (Patient 1, 6, 7, 26 and 27), in accordance with the facility's policy and procedure regarding IV titration medications. Patient 1 and Patient 27 received IV nicardipine (medication to treat high blood pressure) four (4) days and 26 hours and 50 minutes from last administration, respectively. Patient 6's IV Norepinephrine (medication to raise blood pressure) and IV Nicardipine were not discontinued on 5/16/2025 and 5/19/2025, respectively. Patient 7's Nicardipine drip was not discontinued on 5/26/2025. Patient 26 received IV Propofol infusion (an intravenous medication used for sedation) 39 hours and 50 minutes beyond the last administration date of 5/27/2025.

This deficient practice enabled nursing staff to gain access to discontinued medications and administered without physician order. Patient 1 suffered hypotension (low blood pressure) after IV nicardipine (medication to treat high blood pressure) administration. This deficient practice also had the potential to result in putting Patients 6, 7, 26, 27 and other patients receiving IV titratable medications at risk for adverse effects such as severe hypotension, excessive sedation (drowsiness or sleep), respiratory depression (a breathing disorder characterized by slow or shallow breathing that doesn't allow for proper gas exchange in the lungs) and/or death, when the medications were given without valid physician order.

2. There was no parameter range (specific instructions or guidelines to determine the correct administration of a drug) set in the IV titratable medication order (Order set for Nicardipine drip) for one of 41 sampled patients (Patient 6), in accordance with the facility's policy regarding "Titratable Medication Infusion Administration."

This deficient practice had the potential to put Patient 6 and other patients to receive unnecessary medications, which can compromise patient safety due to adverse medication effects such as severe hypotension.

Findings:

1.a. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/24/2025, the "H&P" indicated, Patient 1 was admitted to the facility's Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) with diagnoses including but not limited to subarachnoid hemorrhage (life-threatening type of stroke [a sudden disruption of blood flow to the brain] caused by bleeding into the space surrounding the brain), status post aneurysm coiling (a procedure to treat brain aneurysm [a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst]) on 1/24/2025 and uncontrolled hypertension (high blood pressure).

During a review of Patient 1's "Order Sheet (physician order sheet, orders written by physicians to direct care and treatment)," dated 1/30/2025, the physician order sheet indicated, to give nicardipine (medication to treat high blood pressure) intravenously (IV, administered into a vein) to keep systolic blood pressure (first number of blood pressure when the heart contracts and pushes out blood) less than 180 milliliters of mercury (mmHg, unit of measure) with initial (starting) rate of infusion (running) at 5 milligrams per hour (mg/hr, unit of measure), increment (an increase) of change at 2.5 mg/hr, frequency (how often) of increment of change every 15 minutes, maximum dose rate at 15 mg/hr. The physician order sheet also indicated, "discontinue order if rate remains at zero (0) for 23 hours."

During an interview on 5/28/2025 at 10:56 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: Patient 1 was found nonresponsive (does not react or move) on 2/6/2025 around 5:20 p.m. by Registered Nurse (RN) 1, Patient 1's BP (blood pressure) was 222/116 mmHg at 6 p.m. Patient 1 was sent to radiology (a department that utilizes various imaging techniques to diagnose and treat diseases) for STAT (a medical abbreviation for immediately or without delay) CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head scan. RN 2 received Patient 1 at change of shift at 7 p.m. and noted Patient 1 receiving IV nicardipine at 75 ml/hr (15mg/hr, maximum dose).

During a review of facility's medication dispensing (to supply) record titled, "All Transaction Activity Detail Report (dispensing record)," dated 2/6/2025, the dispensing record indicated, RN 1 retrieved one bag of IV nicardipine 40 mg per 200 milliliters (ml, unit of measure) for Patient 1 on 2/6/2025 at 6:22 p.m.

During a review of facility's medication dispensing (to supply) record titled "All Transaction Activity Detail Report (dispensing record)," dated 2/6/2025, the dispensing record indicated, RN 1 retrieved one bag of IV nicardipine 40 mg per 200 milliliters (ml, unit of measure) for Patient 1 on 2/6/2025 at 6:22 p.m.

During a concurrent interview and record review on 5/28/2025 at 11:24 a.m. with the Stroke Coordinator (SC) 1, Patient 1's "Medication Administration Record (MAR, record of medications given to patients)," dated from 1/31/2025 to 2/6/2025, was reviewed. The MAR indicated, Patient 1 received IV nicardipine infusion starting on 1/31/2025 with initial rate at 5 mg/hr and it was titrated (to adjust the dose) to zero (0) on 2/1/2025 at 7:45 a.m. Nicardipine infusion rate was zero (0) from 2/2/2025 to 2/5/2025. The MAR also indicated, on 2/6/2025 at 7p.m., nicardipine was given at 15mg/hr with a comment indicating, "received patient (Patient 1) at this rate."

During the same interview on 5/28/2025 at 11:24 a.m. with the Stroke Coordinator (SC) 1, SC 1 stated the following: IV nicardipine was started for BP control and it was titrated to zero when the BP was within desired range. Patient 1 did not receive any nicardipine from 2/2/2025 to 2/5/2025. The nicardipine order should have been discontinued on 2/2/2025 by 6:45 a.m. since the last administration (2/1/2025) was over 23 hours. There should be a new order to restart IV nicardipine.

During a concurrent interview and record review on 5/28/2025 at 11:30 a.m. with SC 1, Patient 1's "Vital Signs" flowsheet (vital signs flowsheet), dated 2/6/2025, was reviewed. The vital signs flowsheet indicated the following:

-At 5:40 p.m.: Heart Rate (HR) = 80 beats per minute (bpm), BP = 204/98 mmHg;
-At 6 p.m.: HR = 94 bpm, BP = 222/116 mmHg;
-At 7 p.m.: temperature = 97.9 degrees Fahrenheit (F, unit of measure 100.4 degrees Fahrenheit equivalent to 38.0 degrees Celsius) taken orally, no HR, and no BP documented; and
-at 7:33 p.m.: HR = 70 bpm, BP = 67/40 mmHg.

During the same interview on 5/25/2025 at 11:30 a.m. with the Stroke Coordinator (SC) 1, SC 1 stated the following: there was no monitoring on Patient 1's blood pressure from 6 p.m. to 7:33 p.m. (1.5 hours) while Patient 1 was receiving IV nicardipine. Patient 1 became hypotensive (low blood pressure). Low blood pressure could affect perfusion (process of blood carrying oxygen and nutrients to the body tissues and organs) to the brain and contribute to no blood flow to brain.

During a review of Patient 1's "Physician Communication (physician communication note, documentation between nurse and physician communication regarding patient's condition and test result)" note, dated 2/6/2025, the physician communication note indicated, at 7:28 p.m., RN 2 informed physician (MD 2) that Patient 1 was hypotensive, MD 2 ordered to stop nicardipine and start Levophed (norepinephrine, medication used to raise blood pressure in patients with severe hypotension).

During a review of Patient 1's "Neurosurgery Progress Note (neurosurgeon note, physician progress note completed by neurosurgeon)," dated 2/7/2025, the neurosurgeon note indicated, "(Patient 1) had sudden loss of conscious (unresponsive) yesterday. STAT CT showing large frontal (front part of the brain behind the forehead) hemorrhage (bleeding). Was started on Cardene (nicardipine, medication given intravenously [IV, directly into a vein) to lower blood pressure) for blood pressure management ... became bradycardic (low heart rate) and hypotensive (low blood pressure). Started pressor (medication to raise up the blood pressure) ... loss of brain stem reflexes (involuntary motor responses originating from the brainstem that control breathing, heart rate, and balance) were noted ... this morning remains unresponsive. No cough/gag reflex (a natural protective mechanism that prevents objects from entering the throat and potentially causing choking). No pupillary (relating pupil of the eye) or oculocephalic reflexes (a neurological reflex where the eyes move in the opposite direction of a rapid head rotation). No responses to painful stimuli. And not breathing over the ventilator (an appliance for artificial respiration). It was likely the patient has progressed to brain death (irreversible cessation of all brain function)."

During an interview on 5/30/2025 at 11:56 a.m. with the ICU Director (DIR 2), DIR 2 stated the following: the order of IV nicardipine showed as active on order set because no one discontinued the order as it should have been. This gave RN 1 access to retrieve the medication (Nicardipine) and administered to Patient 1.

During an interview on 5/30/2025 at 12 p.m. with DIR 2, DIR 2 state the following: the facility relied on nurses to check physician orders during shift report to discontinue any IV titration medication when it was not used for over 23 hours. There was room for human error that nurses might forget to remove the order.

During an interview on 5/30/2025 at 12:39 p.m. with the ICU physician (MD 2), MD 2 stated the following: in ICU, the healthcare team would go over patient's titratable medications. The physician could discontinue a medication order, but he (MD 2) expected the nurses to discontinue any IV titratable medications when it was not in use. From the physician's end, he (MD 2) would not know if nurses were doing it (discontinuing the order) or not. It was possible for someone to overlook and not physically discontinue the order.

During an interview on 5/30/2025 at 2:03 p.m. with the Director of Pharmacy (DIR 1), DIR 1 stated the following: the intention to discontinue IV titratable medication after not being used for over 23 hours was to avoid unnecessary medications. If the order remained active, nurses would have access to retrieve the medications. It relied on nursing critical thinking to discontinue the medications. Pharmacy did not have oversight. It was nursing responsibility. DIR 1 also stated the pharmacy was located in the basement and pharmacy staff were not there (in ICU) to check if the IV titratable medications have been stopped for over 23 hours.

During an interview on 5/30/2025 at 4 p.m. with the Medication Safety Officer (MSO), MSO stated Patient 1's nicardipine incident was identified as a medication error because IV nicardipine was restarted despite it (referring to the Nicardipine medication) not used for more than 23 hours (last administration was 2/1/2025) and there was no new order to give IV nicardipine on 2/6/2025. The team performed a root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution) but it (The Nicardipine incident involving Patient 1) was identified as an isolated event.

During an interview on 5/30/2025 at 4:16 p.m. with the Senior Director for Risk Management (SDRM), SDRM stated the following: there was a root cause analysis (RCA) completed involving nursing leadership, pharmacy, stroke team, risk management and quality department on 3/13/2025. The facility had identified there was lack of monitoring and documentation with the IV nicardipine administration, but it was only identified as an individual isolated event. There was no action taken with regard to IV titration medication being given beyond the order time. SDRM also stated the RCA was incomplete because the facility did not look further into IV nicardipine order to identify if there was any systemic problem.

During an interview on 5/30/2025 at 4:41 p.m. with the Chief Medical Officer (CMO), CMO stated the following: the GB was not aware of Patient 1's nicardipine incident and the IV titration medication discontinuation and other order issues. It was a systemic problem and GB owned it. GB would need to do what was right for patients' safety.

During a review of the facility's policy and procedure (P&P) titled, "Titratable Medication Infusion Administration," dated 9/2021, the P&P indicated, "the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Discontinuing a titratable medication. 1. A titratable infusion order will include the order detail that the infusion should be discontinued from the MAR when the patient has not received the medication for 23 hours or more."

During a review of the facility's policy and procedure (P&P) titled, "Medication Errors Reporting," 9/2022, the P&P indicated, "to establish procedures regarding medication errors and encourage all hospital staff to report all medication error reporting as a tool to enhance patient safety and prevent future errors ... Definitions: A. Medication Error - any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer ... Type of medication errors ... d. Administration error - types of administration errors may include: wrong patient, dose, time, medication, route, rate ... and unauthorized dose given ... Medication Error Prevention Team. 1. The pharmacy will use the findings of the medication error prevention and reduction team to develop pharmacy systems and workflow processes designed to prevent medication errors ... All medication errors discovered, as per definition, are subject to a quality assurance review. 2. The primary purpose of the quality assurance review is to advance error prevention by analyzing the cause and contributing factors such as system or process failures."

During a review of the facility's policy and procedure (P&P) titled, "Quality Assessment, Performance Improvement Plan (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital)," dated 3/2024, the P&P indicated, "Scope: As part of performance improvement, leaders (including governing body) will: 1. Set priorities (i.e. high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines. 2. Identify frequency of data collection for performance improvement. 3. Prioritize performance improvement in response to changes within the internal and external environment. 4. Proactively identify processes needing improvement to prevent medical errors. 5. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performances of process improvement/deficiencies, and monitoring/sustaining processes ... Structure and Accountability ... 1. The Community Board (governing body [GB]) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectation for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital's performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective [the facility's] committees/ teams."

1.b. During a review of Patient 6's "History and Physical (H&P)," dated 5/14/2025, the "H&P" indicated, Patient 6 was admitted to the facility's Intensive Care Unit (ICU) with diagnoses including but not limited to subarachnoid hemorrhage (life-threatening type of stroke caused by bleeding into the space surrounding the brain), ruptured (burst) aneurysm (a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst]) and acute (new onset) hypoxic (deficiency in the amount of oxygen reaching the tissues) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).

During a review of Patient 6's physician order, dated 5/14/2025, the physician order indicated, to give norepinephrine (medication to raise blood pressure) intravenously (IV) to keep mean arterial pressure (MAP, a measurement of the average arterial blood pressure throughout one cardiac [heart] cycle) greater than 65 mmHg with initial rate of infusion 4 micrograms per minutes (mcg/min, unit of measure), increment of change at 2mcg/min, frequency of increment of change at 2 minutes (min, unit of measure), maximum dose 30mcg/min. The physician order sheet also indicated, "discontinue order if rate remains at zero (0) for 23 hours." The physician order also indicated the order was discontinued on 5/22/2025.

During a review of Patient 6's physician order, dated 5/15/2025, the physician order indicated, to give nicardipine (medication to treat high blood pressure) intravenously (IV) to keep systolic blood pressure (SBP) less than 160 mmHg, unit of measure with initial rate of infusion at 5 mg/hr, increment of change at 2.5 mg/hr, frequency of increment of change every 15 minutes, maximum dose rate at 15 mg/hr. The physician order sheet also indicated, "discontinue order if rate remains at zero (0) for 23 hours." The physician order also indicated the order was discontinued on 5/22/2025.

During a concurrent interview and record review on 5/29/2025 at 3:44 p.m. with the program manager (PM) 2 for chest pain compliance and audit, Patient 6's "Medication Administration Record (MAR)," dated from 5/15/2025 to 5/22/2025, was reviewed. The MAR indicated the following:
-IV norepinephrine was started on 5/14/2025 at 15 mcg/min and titrated to zero (0) on 5/15/2025 at 2 a.m. There was no IV norepinephrine infusion from 5/16/2025 to 5/22/2025; and
-IV nicardipine was started on 5/15/2025 at 5 mg/hr and titrated to zero (0) on 5/18/2025 at 8 a.m. There was no IV nicardipine infusion from 5/19/2025 to 5/22/2025.

During the same interview on 5/29/2025 at 3:44 p.m. with the program manager (PM) 2, PM 2 stated the following: IV norepinephrine should be discontinued on 5/16/2025 by 2 a.m., 23 hours from the last administration (5/15/2025 at 2 a.m.) and IV nicardipine should be discontinued on 5/19/2025 by 8 a.m., 23 hours from last administration (5/18/2025 at 8 a.m.). Either the nurse or physician could discontinue the orders. There would be potential for nursing staff to get the medication and give to patient if it was not discontinued. It was out of nursing scope of practice to give medication without a physician order.

During an interview on 5/30/2025 at 4:41 p.m. with the Chief Medical Officer (CMO), CMO stated the GB was not aware the IV titration medication discontinuation and other order issues. It was a systemic problem and GB owned it. GB would need to do what was right for patients' safety.

During a review of the facility's policy and procedure (P&P) titled, "Titratable Medication Infusion Administration," dated 9/2021, the P&P indicated, "the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Discontinuing a titratable medication. 1. A titratable infusion order will include the order detail that the infusion should be discontinued from the MAR when the patient has not received the medication for 23 hours or more."

During a review of the facility's policy and procedure (P&P) titled, "Medication Errors Reporting," 9/2022, the P&P indicated, "to establish procedures regarding medication errors and encourage all hospital staff to report all medication error reporting as a tool to enhance patient safety and prevent future errors ... Definitions: A. Medication Error - any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer ... Type of medication errors ... d. Administration error - types of administration errors may include: wrong patient, dose, time, medication, route, rate ... and unauthorized dose given ... Medication Error Prevention Team. 1. The pharmacy will use the findings of the medication error prevention and reduction team to develop pharmacy systems and workflow processes designed to prevent medication errors ... All medication errors discovered, as per definition, are subject to a quality assurance review. 2. The primary purpose of the quality assurance review is to advance error prevention by analyzing the cause and contributing factors such as system or process failures."

During a review of the facility's policy and procedure (P&P) titled, "Quality Assessment, Performance Improvement Plan (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital)," dated 3/2024, the P&P indicated, "Scope: As part of performance improvement, leaders (including governing body) will: 1. Set priorities (i.e. high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines. 2. Identify frequency of data collection for performance improvement. 3. Prioritize performance improvement in response to changes within the internal and external environment. 4. Proactively identify processes needing improvement to prevent medical errors. 5. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performances of process improvement/deficiencies, and monitoring/sustaining processes ... Structure and Accountability ... 1. The Community Board (governing body [GB]) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectation for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital's performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective [the facility's] committees/ teams."

1.c. During a review of Patient 7's "History and Physical (H&P)," dated 5/9/2025, the H&P indicated, Patient 7 was admitted to the facility's Intensive Care Unit (ICU) with diagnoses including but not limited to acute (new onset) subarachnoid hemorrhage, metabolic encephalopathy (a broad term for any brain disease that alters brain function or structure) and acute ventilator (an appliance for artificial respiration) dependent respiratory failure (a condition where the lungs cannot adequately transfer oxygen into the blood or remove carbon dioxide, leading to a buildup of carbon dioxide and a deficiency of oxygen).

During a review of Patient 7's "Order Sheet (physician order)," dated 5/14/2025, the physician order indicated to give nicardipine intravenously (IV) to keep systolic blood pressure (SBP) less than 180 mmHg with initial rate of infusion at 5 mg/hr, increment of change at 2.5 mg/hr, frequency of increment of change every 15 minutes, maximum dose rate at 15 mg/hr. The physician order sheet also indicated, "discontinue order if rate remains at zero (0) for 23 hours." The physician order also indicated the order was discontinued on 5/28/2025.

During a concurrent interview and record review on 5/29/2025 at 4:23 p.m. with ICU RN 11, Patient 7's "Medication Administration Record (MAR)," dated from 5/19/2025 to 5/28/2025, was reviewed. The MAR indicated Patient 7 received IV nicardipine infusion from 5/19/2025 to 5/25/2025. IV nicardipine infusion was titrated to zero (0) on 5/25/2025 at 6 a.m. There was no IV nicardipine infusion from 5/26/2025 to 5/28/2025.

During the same interview 5/29/2025 at 4:23 p.m. with ICU RN 11, RN 11 stated the following: nurse should have discontinued the order on 5/26/2025 by 5 a.m., 23 hours after the last administration (5/25/2025 at 6 a.m.). The medication was not needed anymore. Nurses could discontinue the order without calling the physician. There would be potential for nurses to restart the medication without communicating with the physician when the order remained active. Nurse should contact the physician when patient had change of condition so the physician could evaluate the patient.

During an interview on 5/30/2025 at 4:41 p.m. with the Chief Medical Officer (CMO), CMO stated the GB was not aware the IV titration medication discontinuation and other order issues. It was a systemic problem and GB owned it. GB would need to do what was right for patients' safety.

During a review of the facility's policy and procedure (P&P) titled, "Titratable Medication Infusion Administration," dated 9/2021, the P&P indicated, "the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Discontinuing a titratable medication. 1. A titratable infusion order will include the order detail that the infusion should be discontinued from the MAR when the patient has not received the medication for 23 hours or more."

During a review of the facility's policy and procedure (P&P) titled, "Medication Errors Reporting," 9/2022, the P&P indicated, "to establish procedures regarding medication errors and encourage all hospital staff to report all medication error reporting as a tool to enhance patient safety and prevent future errors ... Definitions: A. Medication Error - any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer ... Type of medication errors ... d. Administration error - types of administration errors may include: wrong patient, dose, time, medication, route, rate ... and unauthorized dose given ... Medication Error Prevention Team. 1. The pharmacy will use the findings of the medication error prevention and reduction team to develop pharmacy systems and workflow processes designed to prevent medication errors ... All medication errors discovered, as per definition, are subject to a quality assurance review. 2. The primary purpose of the quality assurance review is to advance error prevention by analyzing the cause and contributing factors such as system or process failures."

During a review of the facility's policy and procedure (P&P) titled, "Quality Assessment, Performance Improvement Plan (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital)," dated 3/2024, the P&P indicated, "Scope: As part of performance improvement, leaders (including governing body) will: 1. Set priorities (i.e. high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines. 2. Identify frequency of dada collection for performance improvement. 3. Prioritize performance improvement in response to changes within the internal and external environment. 4. Proactively identify processes needing improvement to prevent medical errors. 5. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performances of process improvement/deficiencies, and monitoring/sustaining processes ... Structure and Accountability ... 1. The Community Board (governing body [GB]) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectation for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital's performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective [the facility's] committees/ teams."

1.d. During a review of Patient 26's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/19/2025, the H&P indicated that Patient 26 was admitted to the facility with a diagnosis of status epilepticus (a continuous seizure [a temporary disruption of normal electrical activity in the brain that can cause changes in behavior, movement, or awareness] lasting five minutes or more, or recurrent seizures without recovery in between) and had to be intubated (a tube has been inserted into the patient's windpipe (trachea) through their mouth or nose to help them breathe).

During a review of Patient 26's medical record (MR) titled, "Order Sheet," dated 5/19/2025, the MR indicated that on 5/19/2025 at 5:58 a.m., the physician placed an order set for propofol (an intravenous medication used for sedation) to be given as a continuous infusion (titratable drip- slowly increasing the dose of a medicine by very small amounts over time) at initial rate of 10 micrograms per kilogram per minute (mcg/kg/min, measuring unit) .... Order comments indicated the following details:
-" ...Discontinue Order if rate remains at zero [0] for 23 hours ..."

During a concurrent interview and record review on 5/29/2025 at 3:46 p.m. with registered nurse (RN) 6, Patient 26's "Medical Administration Record (MAR)," dated 5/19/2025 through 5/29/2025, was reviewed. RN 6 stated that on 5/26/2025 at 10:09 a.m., the recorded (in patient 26's MAR) rate for propofol was 0 mg/hr. RN 6 said that on 5/28/2025 at 1:59 a.m., propofol drip was restarted at 53.3 mg (over 39 hours and 50 minutes beyond the last administration time on 5/26/2025). RN 6 also said that because the order set for propofol indicated that the medication should be discontinued if the rate remains at zero for 23 hours, this order should have been discontinued, and a new order should have been placed to restart the propofol infusion (on 5/28/2025).

During an interview on 5/30/2025 at 11:27 a.m. with the Critical Care Director (Dir 2), the Dir 2 stated, "Nurses have to verify any medication order ...ensuring the order is active before administering a medication ... If the medication order indicated to discontinue after 23 hours of not being used, then nurses should discontinue and obtain a new order if the same medication needs to be administered again ...Nurses cannot make any changes to the order without communicating with the physician [medical provider] first and obtaining the approval .... All verbal orders must be documented in the patient's medical record, and it is the responsibility of either the nurse or the physician to ensure that this documentation is completed."

During an interview on 5/30/2025 at 4:41 p.m. with the Chief Medical Officer (CMO), CMO stated the GB was not aware about the IV titration medication discontinuation and other order issues. It was a systemic problem and GB owned it. GB would need to do what was right for patients' safety.

During a review of the facility's policy and procedure (P&P) titled, "Titratable Medication Infusion Administration," dated 9/2021, the P&P indicated,

Based on interview and record review, the Governing Body (GB), responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision making, failed to ensure patient care and services rendered under contract with an outside entity (Radiology Services, provide imaging technology to diagnose and treat medical conditions. Radiologists, who are medical doctors specializing in radiology, interpret these images to aid in diagnosis and treatment planning), adhered to Radiology contract service expectations for timely (in less than 30 minutes) computed tomography (CT scan, medical imaging creates detailed images of the inside of the body) interpretation for one of five sampled patients (Patient 4) in the Emergency Department (ED), in accordance with the facility's policy regarding contract processing and service agreement.

This deficient practice resulted in a delay in 2-hours and 24-minutes in the interpretation of Patient 4's CT of the brain, which delayed potentially life-saving intervention and contributed to a high likelihood of irreversible neurological damage (injury or harm that affects the brain, spinal cord [a bundle of nerves running down the spine]). Additionally, this deficient practice had the potential to cause delays in care for other patients presenting to the emergency department (ED) who require emergent CT interpretation for time-sensitive conditions.

Findings:

During a concurrent interview and record review on 5/28/2025 at 11:30 a.m. with the Stroke Program Manager/Coordinator (SC) 1, Patient 4's "ED Physician Notes," documented by ED physician (MD 4) and dated 2/18/2025, were reviewed. The notes indicated Patient 4 was brought to the ED (Emergency Department) for elevated blood pressure and complaints of nausea (a feeling of sickness) and vomiting for 12 hours. Patient 4's blood pressure was over 200 systolic (the top number in a blood pressure reading). MD 4 documented that Patient 4 appeared drowsy (half-asleep; sleepy) and mildly confused (not be able to think or speak clearly). CT (Computed Tomography- medical imaging creates detailed images of the inside of the body) head and CT abdomen/pelvis were pending. MD 4 noted concern for hypertensive encephalopathy (a serious condition where a sudden, severe elevation in blood pressure causes brain dysfunction).

During the same interview on 5/28/2025 at 11:30 a.m. with the Stroke Program Manager/Coordinator (SC) 1, SC 1confirmed that MD 4's differential diagnoses (process is used to help make a final diagnosis when you have symptoms that don't have one clear cause) included intercranial bleeding (bleeding in the brain), meningitis (an infection and swelling, called inflammation, of the brain), encephalitis (swelling of the brain), migraine headache (a headache that can cause severe throbbing pain), and cerebrovascular accident (CVA, also known as a stroke), indicating the physician was concerned about Patient 4's head due to presenting symptoms of hypertension, being drowsy, and mildly confused.

During the same interview on 5/28/2025 at 11:30 a.m. with the Stroke Program Manager/Coordinator (SC) 1, Patient 4's "ED Physician Notes," documented by ED physician (MD 5), was reviewed. MD 5 documented that the patient (Patient 4) was "signed out to me by my colleague to follow-up on CT results." Upon rounding, MD 5 found that Patient 4 was very somnolent (abnormally drowsy) and presented with a new neurological deficit (a problem with the normal function of the brain, spinal cord, nerves, or muscles, resulting in abnormal function of a body part), including a right-sided facial droop and inability to move the left upper and lower extremities. A Code Stroke (initiation of an emergency response when a patient is suspected of having a stroke [a medical emergency that occurs when the brain's blood supply is disrupted, causing brain damage]) was activated. SC 1 confirmed that the CT scan resulted at 6:33 a.m., prior to MD 5 discovering Patient 4 with stroke-like symptoms.

During a concurrent interview and record review on 5/28/2025 at 12:00 p.m. with the Stroke Program Manager/Coordinator (SC) 1, Patient 4's medical record document titled, "Orders," dated 2/18/2025 at 2:59 a.m., was reviewed. The order indicated that MD 4 requested a STAT (a one-time order that is served immediately due to urgent circumstances) CT of the brain for evaluation of a headache. SC 1 stated the CT scan was completed at 4:09 a.m., and the interpretation was at 6:33 a.m. (after 2-hours and 24-minutes following completion of test). SC 1 said "This represents a delay of 2 hours and 54 minutes beyond the contract agreement with Radiology Services, which requires interpretation within 30 minutes."

During an interview on 5/28/2025 at 2:40 p.m. with the Director of Imaging Services (DIS) 1, DIS 1 stated during after-hours (5 p.m. to 6:30 a.m.), the contracted radiology service interpreted imaging studies. DIS 1 stated that both in-house and contracted radiologists were expected to interpret CT scan within 60 minutes. If interpretation was delayed, radiology technicians were expected to follow up with a call. However, no documentation of such follow-up was required, and none was recorded in Patient 4's case.

During an interview on 5/28/2025 at 4:20 p.m. with the Medical Director of Radiology (MDR) 1, MDR 1 stated that for patients presenting with headache and elevated blood pressure, the expectation was, the CT was to be interpreted within 30 minutes. If the contracted radiology group cannot meet this expectation, the technologist should escalate the request to an on-call radiologist. MDR 1 stated that changes in the radiologist schedule now resulted in the contracted service beginning coverage earlier at 5:00 p.m. instead of 7:00 p.m.

During an interview on 5/29/2025 at 11:33 a.m. with the Medical Director of the Emergency Department (MDED), MDED stated, that in-house CT interpretations typically occurred within 10 minutes, but during night shifts when the contracted radiology group was used, reads may take 1 to 2 hours." MDED stated If the physician was concerned, they may call the radiologist for a read sooner. MDED stated that faster results were critical for timely treatment and clinical decision-making.

During an interview on 5/29/2025 at 11:33 a.m. with the ED physician (MD 4), MD 4 confirmed that CT read times were variable and can sometimes take up to two hours or more to receive results.

During an interview on 5/30/2025 at 4:40 p.m. with the Director of Quality Assurance and Performance Improvement (DOQ), the DOQ stated that contract performance for radiology services was monitored by the Chief Medical Officer (CMO), who was the contract owner/contract manager responsible for completing an "Annual Review Summary" and "Annual Appraisal of Clinical Patient Care Contracted Services," in accordance with CMS (Center for Medicare and Medicaid Services) Requirement, Section 482, and submitting them to Quality Assurance and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) committee, which oversees the facility's quality monitoring and improvement efforts. The DOQ stated that only one Annual Review Summary had been submitted (in 2022) since the contract became effective on 11/1/2020. Reviews for 2021, 2023, and 2024 were not submitted, and therefore not communicated to Governing Body (GB). The DOQ also confirmed that the "Annual Appraisal of Clinical Patient Care Contracted Services" form was never submitted to QAPI.

During an interview on 5/30/2025 at 5:00 p.m. with the Chief Medical Officer (CMO), the CMO stated that the position (CMO) had been vacant from August 2024 to March 2025. The current CMO acknowledged being aware of delays in CT interpretations by the contracted radiology service and noted that communication with the vendor had taken place to address the issue. CMO further indicated that the facility was currently exploring options, including the possibility of transitioning to a different radiology contract service to better support timely imaging interpretation.

During a review of the facility's policy and procedure (P&P) titled, "Contract Processing," dated 2/2/2023, the P&P indicated, "(name of the facility) is committed to ensuring that all contractual arrangements (i) are in compliance with all regulatory and legal requirements ...Contract Manager: The AH employees who have principal responsibility for the drafting, reviewing, processing, and managing of contracts. All nonphysician Contracts are processed within the contract management program by the corporate shared services contract management team & corporate sourcing team. The Contract Manager collaborates with the Business Owners to monitor the contract portfolio for annual reviews, upcoming expirations and/or renewals. Based upon Business Owner input, the Contract Manager terminates or renews contracts as appropriate."

During a review of the facility's "Radiology Department Professional and Medical Director Services Agreement," dated 5/29/2025, the Agreement indicated that emergency department study reports were expected to be completed in less than 30 minutes, and all stat studies in less than 45 minutes. Reports must be electronically signed within 24 hours of procedure completion.

During a review of the facility's policy and procedure (P&P) titled, "Quality Assessment, Performance Improvement Plan (QAPI)," dated 3/13/2024, the P&P indicated, "The Community Board (GB) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectations for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital's performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective (name of the facility) committees/teams."

Based on interview and record review, the facility failed to:

1. Protect one of 19 sampled patients (Patient 3) in the Psychiatric (relating to mental illness) Acute Care (PAC) unit, from an assault (an act that threatens physical harm to a person, whether or not actual harm is done), in accordance with the facility's protocol regarding provision of a safe environment of care, when Patient 2 entered Patient 3's room for approximately 2 to 3 minutes, with no staff members present in the hallway while Patient 2 entered Patient 3's room.

This deficient practice resulted in Patient 2 (male patient) entering Patient 3's room, resulting in scratches to Patient 3's (female patient) upper and lower lip and had the potential to result in serious injury or harm. In addition, after the incident, Patient 3 became anxious, watchful, fearful, scared, and constantly looking over her shoulder.

2. Ensure one of two sampled Behavioral Health Unit (BHU, a specialized area within a hospital dedicated to providing mental health care) staff (Licensed Vocational Nurse 2), completed her "Abuse and Neglect" module (training module that discusses the types of abuse [refers to any action or failure to act by a caregiver that causes harm or distress to a patient, encompassing various forms like physical, emotional, sexual, and financial abuse, as well as neglect] and neglect, the related indicators and the reporting responsibilities of health care providers) yearly, in accordance with the facility's annual education requirements.

This deficient practice had the potential for violations of patient rights such as being free from all forms of abuse, due to lack of staff training.

On 5/29/2025 at 12:22 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Medical Officer (CMO), the Senior Director for Risk Management (SDRM), the Patient Care Executive/Chief Nursing Officer (CNO), the Director of Quality (DOQ), and via telephone, the Director for Accreditation and Licensing (DAL).

Patient 2 was admitted to the facility, on 4/19/2025, on a 5150 Hold (72 - hour involuntary hold) for Grave Disability (a person who is unable to care for their basic needs due to a mental health disorder). Patient 3 was admitted to the facility on 5/01/2025, on a 5150 Hold for suicidal ideations (thought of harming oneself). A review of video footage in the Psychiatric Acute Care (PAC) Unit, dated 5/07/2025 indicated the following: At 7:55 a.m., Patient 2 entered Patient 3's room, located across the hall, no staff (certified nurse assistants, licensed vocational nurses, or registered nurses) were in the hallway at that time. At 7:57 a.m., Patient 2 and Patient 3 walked out of Patient 3's room. Patient 2 walked back to his (Patient 2) room. Patient 3 lingered in the hallway. At 7:58 a.m., Licensed Vocational Nurse (LVN) 1 was talking to Patient 3 in the hallway. Per LVN 1, Patient 3 reported that Patient 2 entered her (Patient 3) room, placed his (Patient 2) hand over her (Patient 3) mouth, which caused scratches to Patient 3's face. In addition, Patient 3 was anxious and scared after Patient 2 entered her (Patient 3) room.

On 5/30/2025 at 5:49 p.m., the IJ was removed in the presence of the CMO, SDRM, CNO, DOQ, the Regulatory Specialist (RS), and the DAL via telephone. The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The acceptable IJ Removal Plan included the following: Every 15 minutes observation, staff must enter the patient room to verify patient status and document findings in real time. A dedicated hallway observer (either a Mental Health Worker or Certified Nurse Assistant) is assigned each shift. The dedicated hallway observer has no other patient care duties, monitors patient movement and behavior ...prevents cross-room entry by other persons and must call the lead and resource nurse before stepping away. A standardized hourly rounding log was implemented for licensed nursing staff. In-person education was provided to staff on the psychiatric units. In addition, there will be daily, unannounced, observation audits, video surveillance audits 5 times per week, and review of assignment to ensure inclusion of the hallway observer each shift.

Findings:

1. During a review on 5/28/2025 at 10:25 a.m., a video footage, dated 5/7/2025, of the East side of the Psychiatric (relating to mental illness) Acute Care Unit, was reviewed. The following was reviewed with Nurse Managers (NM) 1 and NM 2, and the Director of Security (DOS). The video footage indicated the following: At 7:55 a.m., Patient 2 (male) exited his (Patient 2) room and entered Patient 3's (female) room, located across the hall. No staff (registered nurses [RN] or licensed vocational nurses [LVNs]) were present in the hallway at this time. At 7:57 a.m., Patient 2 and Patient 3 walked out of Patient 3's room. Patient 2 walked back to his (Patient 2) room across the hall. Patient 3 lingered in the hallway. At 7:58 a.m., Licensed Vocational Nurse (LVN) 1 went into Patient 2's room, then LVN 1 was seen talking to Patient 3 in the hallway. At 8:15 a.m., Registered Nurse (RN) 5 went into Patient 2's room. At 8:17 a.m., Registered Nurse (RN) 4 and Patient 2 walked out of Patient 2's room. Patient 2 was carrying his (Patient 2) belongings.

During an interview on 5/28/2025 at 10:25 a.m. with Nurse Managers (NM) 1 and 2, NM 1 and NM 2 verified that Patient 2 entered Patient 3's room, which was a single room. Patient 3 was alone with Patient 2 for two to three minutes. NM 1 stated Patient 3's safety was at risk. Patient 2 was moved to another unit following the incident. NM 1 stated Registered nurses were required to conduct hourly rounds on their assigned patients.

During an interview on 5/28/2025 at 2:08 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she (LVN 1) saw Patient 2 come out of Patient 3's room. LVN 1 instructed Patient 2 to go back to his (Patient 2) room. LVN 1 stated Patient 3 said a male patient entered her (Patient 3) room and demonstrated, by placing her (Patient 3) hand over her mouth, that Patient 2 covered her (Patient 3) mouth. LVN 1 further stated Patient 3 had a small red mark on the right side of her nose and right upper lip. Patient 3 was anxious and scared after Patient 2 entered her (Patient 3) room. LVN 1 reported the incident to Registered Nurse (RN) 4 and RN 5.

During a second interview on 5/28/2025 at 4:14 p.m. with NM 1, NM 2, NM 1 and NM 2 stated that on 5/7/2025 between 7 a.m. and 8 a.m., it was breakfast time, staff were busy handing out breakfast trays and LVN 1 was conducting rounds (a systematic process where healthcare professionals, like nurses, regularly visit patients to assess their condition) every 15 minutes. NM 1 further stated that since 5/12/2025, the facility implemented a new practice where the RN had to be on the floor and not just at the Nurses station to visualize patient movements at all times.

During a review of Patient 2's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/19/2025, the H&P indicated the following: Patient 2 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for Grave Disability (a person who is unable to care for their basic needs due to a mental health disorder).

During a review of Patient 3's History and Physical (H&P), dated 5/01/2025, the H&P indicated Patient 3 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for suicidal ideations (thoughts of harming self).

During a review of Patient 3's "Clinical Note Nursing," dated 5/7/2025 at 1:54 p.m., the Clinical Note indicated the following: At 7:30 a.m., Patient 3 approached staff stating a male patient entered her (Patient 3) room and put his (Patient 2) hand on her (Patient 3) face: Patient 3 appeared anxious, fearful but refused to give any more information ...Patient 3 observed to have a small, superficial scratches on her right upper lip and one (scratch) on the left lower lip ...

During a review of Patient 3's "Clinical Note Nursing," dated 5/7/2025 at 4:25 p.m., the Clinical Note indicated the following: "patient (Patient 3) is alert ...appears paranoid, watchful, looking over her shoulder, appears fearful when approached by staff; patient (Patient 3) stated a male patient came into her room at around 7:30 a.m., and put his (Patient 2) hand on her face, causing two superficial scratches on her upper and lower lip ..."

During a review of the facility's policy and procedure (P&P) titled, "Assault and Abuse (refers to any action or failure to act by a caregiver that causes harm or distress to a patient, encompassing various forms like physical, emotional, sexual, and financial abuse, as well as neglect) Reporting for Staff and Management," dated 9/27/2021, the P&P indicated the following ... Assaultive and/or abusive behavior often results in significant physical and mental suffering to the victim ... This policy serves to: 1. Promote a safer environment for our patients. 2. Heighten awareness of the realities of assault, abuse, neglect, and misconduct against vulnerable members of society ... B. The patient's safety and welfare is always your first concern. Thoroughly assess the patient (and intervene accordingly) to address any immediate medical or psychosocial needs...

During a review of the facility's "Handbook," relating to Rights of Individuals in Mental Health Facilities, dated 8/2016, the Handbook indicated the following: Your Right as a Patient ...The person in charge of the facility in which you are receiving treatment is responsible for ensuring that all your rights in this handbook are protected ...The right to be free from abuse or neglect: You have the right to be free from abuse, neglect, or harm ...
During a review of a facility's undated document titled, "Patient Rights," the document indicated "You have the right to ...Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect ..."

2. During a concurrent interview and record review on 05/29/2025 at 2:30 p.m. with the Director of Behavioral Health (DBH) 1, LVN 2's "Healthstream (a web-based learning management platform)" training records, was reviewed. The record indicated that LVN 2 failed to complete her (LVN 2) yearly training on abuse. The last abuse training module titled, "[Name of Facility] 2013 Assault and Abuse Reporting RN/LVN Competency," was completed on 08/09/2017. DBH 1 stated that abuse training must be completed by all direct patient care staff yearly. LVN 2 had no record of completing her annual abuse training.

During a concurrent interview and record review on 05/29/2025 at 3:19 p.m. with the Education Manager (EM 1), the personnel records, specifically, the training records titled, "To Do List" for LVN 2, undated, were reviewed. The record indicated that LVN2 failed to complete her yearly training on abuse titled, "SQ: Clinical Rapids Review." The records indicated that LVN 2's last completion of training was 09/01/2024.

During the same interview on 05/29/2025 at 3:19 p.m. with the Education Manager (EM 1), EM 1 stated that the "Abuse and Neglect" training module was under "SQ: Clinical Rapid Review" Course. This course was mandatory for all direct patient care nurses and must be completed yearly. LVN 2 was a current active employee in BHU and should have completed her annual training on "Abuse and Neglect." This training was important because it helps staff identify abuse and the facility's abuse reporting process.

Based on interview and record review, the facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI, a data-driven, facility-wide program designed to monitor, assess, and improve the quality and safety of patient care) program included monitoring and oversight of services provided under contract, specifically radiology services (provide imaging technology to diagnose and treat medical conditions. Radiologists, who are medical doctors specializing in radiology, interpret these images to aid in diagnosis and treatment planning), to ensure timely (in less than 30 minutes) computed tomography (CT scan, medical imaging creates detailed images of the inside of the body) interpretation for one of five sampled patients (Patient 4) in the Emergency Department (ED), in accordance with the facility's performance improvement policy. Additionally, the hospital failed to establish an ongoing process to measure, analyze, and track performance indicators related to contracted radiology services, as required, to support and improve health outcomes and quality of care.

This deficient practice resulted in the lack of timely identification and response to performance issues that directly affected patient care, including delays in emergency CT interpretation for Patient 4. This deficient practice had the potential for delays in the delivery of necessary care interventions for Patient 4 and other patients in the facility.

Findings:

During a concurrent interview and record review on 5/28/2025 at 11:30 a.m. with the Stroke Program Manager/Coordinator (SC 1), Patient 4's "ED Physician Notes," documented by Emergency Department (ED, a hospital facility that provides immediate medical care to patients who need urgent attention) physician (MD 4) and dated 2/18/2025, were reviewed. The notes indicated Patient 4 was brought to the ED for elevated blood pressure and complaints of nausea (a feeling of sickness) and vomiting for 12 hours. Patient 4's blood pressure was over 200 systolic (the top number in a blood pressure reading). MD 4 noted that Patient 4 appeared "drowsy (half-asleep; sleepy) and mildly confused (not be able to think or speak clearly)," and ordered a STAT (a one-time order that is served immediately due to urgent circumstances) computed tomography (CT scan, medical imaging creates detailed images of the inside of the body) of the brain at 2:59 a.m. SC 1 confirmed that MD 4's differential diagnoses (process is used to help make a final diagnosis when you have symptoms that don't have one clear cause) included intercranial bleeding (bleeding in the brain. The scan was completed at 4:09 a.m. but was not interpreted until 6:33 a.m. a delay of 2 hours and 24 minutes.

During the same interview on 5/28/2025 at 11:30 a.m. with the Stroke Program Manager/Coordinator (SC 1), Patient 4's "ED Physician Notes," documented by ED physician (MD 5), was reviewed. MD 5 noted that the patient (Patient 4) "was signed out to me by my colleague to follow-up on CT results." Upon rounding (a systematic process where a healthcare team member checks on a patient regularly), MD 5 found that Patient 4 was very somnolent (abnormally drowsy) and presented with a new neurological deficit (a problem with the normal function of the brain, spinal cord, nerves, or muscles, resulting in abnormal function of a body part), including a right-sided facial droop (sagging appearance of one side of the face due to weakness or paralysis of the facial muscles) and inability to move the left upper and lower extremities. A Code Stroke (initiation of an emergency response when a patient is suspected of having a stroke [a medical emergency that occurs when the brain's blood supply is disrupted, causing brain damage]) was activated. SC 1 stated timely availability of CT scan results was important in the evaluation of patients with suspected stroke, noting that early interpretation was critical for initiating appropriate interventions. The SC 1 confirmed that a delay in CT interpretation could potentially contribute to the delayed recognition and treatment of a suspected stroke, placing the patient at risk for serious, and potentially irreversible neurological (affect the brain as well as the nerves found throughout the human body and the spinal cord) harm.

During an interview on 5/30/2025 at 4:40 p.m. with the Director of Quality Assurance and Performance Improvement (DOQ), the DOQ stated that contract performance for radiology services was monitored by the Chief Medical Officer (CMO), who was responsible for completing an "Annual Review Summary" and "Annual Appraisal of Clinical Patient Care Contracted Services," in accordance with CMS (Centers for Medicare and Medicaid Services) Requirement, Section 482, and submitting them to Quality Assurance and Performance Improvement (QAPI, a data-driven, facility-wide program designed to monitor, assess, and improve the quality and safety of patient care)) committee, which oversees the facility's quality monitoring and improvement efforts. The DOQ stated both forms were intended to evaluate contractor performance. However, no such evaluations had been submitted for radiology contractor, and no reports or summaries regarding radiology performance were available for review. The DOQ stated that only one Annual Review Summary had been submitted (in 2022) since the contract became effective on 11/1/2020. Reviews for 2021, 2023, and 2024 were not submitted, and therefore not communicated to Governing Body (GB). The DOQ also confirmed that the "Annual Appraisal of Clinical Patient Care Contracted Services" form was never submitted to QAPI.

During an interview on 5/30/2025 at 5:00 p.m. with the Chief Medical Officer (CMO), the CMO confirmed that the radiology contract had not been renewed since 2021, and that the oversight process for contract performance had been disrupted due to a vacancy in the CMO role from August 2024 to March 2025. The CMO stated that although discussions had occurred with the radiology vendor after assuming the role in March 2025, performance data had not been consistently provided to QAPI, and no formal analysis or follow-up actions had been initiated regarding CT delays.

During a review of the facility's policy and procedure (P&P) titled, "Quality Assessment, Performance Improvement Plan (QAPI)," dated 3/13/2024, the P&P indicated, "As part of performance Improvement, leaders (including governing body) will: Set priorities (re high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines. Identify frequency of data collection for performance improvement. Prioritize performance improvement in response to changes within the internal and external environment. Proactively identify processes needing improvement to prevent medical errors. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performance of process improvement/deficiencies, and monitoring/sustaining processes. Annually review performance improvement plan/priorities and update to reflect changes in strategic priorities and/or environment. Determine annual performance improvement projects proportional to scope and complexity of hospital services and operations ... Patient safety integrates with all quality assessment and performance Improvement activities. Proactive Risk Assessments ...will be utilized to assess actual and potential risk, failure, points of vulnerability, and prioritized areas for improvement based on impact to patient care outcomes ..."

Based on interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI, a data-driven, facility-wide program designed to monitor, assess, and improve the quality and safety of patient care) committee failed to:

1. Analyze and track an adverse patient event (any unfavorable or unintended occurrence), in accordance with the facility's policy regarding performance improvement, when it failed to conduct a thorough investigation for an allegation of an assault (an act that threatens physical harm to a person, whether or not actual harm is done) that was reported by one of 41 sampled patients (Patient 3) on 5/7/2025, when Patient 2 entered Patient 3's room and covered Patient 3's mouth, which resulted to visible scratches to Patient 3's upper and lower lip. In addition, the facility failed to report the incident to the regulatory agency within 24 hours of the incident, in accordance with the facility's policy regarding adverse event reporting.

This deficient practice led to an incomplete investigation of the alleged Patient 2 assault on Patient 3 and resulted in the facility not reporting the assault within 24 hours to the regulatory agency resulting in a delay of investigation of the incident. This deficient practice of not analyzing and tracking adverse patient events also had the potential for the facility's inability to adequately identify and address issues, leading to an increased risk of preventable harm to patients.

2. Ensure its Quality Assurance and Performance Improvement (QAPI) team performed a thorough investigation for one of 41 sampled patient's (Patient 1) medication safety event on 2/6/2025 (Patient 1 was re-started on a Nicardipine drip [medication to treat high blood pressure] without a proper physician order which caused a sudden drop in Patient 1's blood pressure) and identify a systemic failure regarding IV titratable medication order discontinuation, in order to prevent two other patients (Patient 26 and 27) from receiving an IV titratable medication that should have been discontinued, in accordance with the facility's policies regarding performance improvement and IV titratable medications.

This deficient practice, regarding the lack of a thorough investigation into Patient 1's medication safety event, resulted in no action plan implemented to ensure IV titratable medications were discontinued per physician orders, thus leading to other incidents involving other patients (Patient 26 and Patient 27) receiving IV titration medications, which should have been discontinued 23 hours after the last administration, as well as putting patients at risk for harm and potential to experience complications.

Findings:

1. During a review on 5/28/2025 at 10:25 a.m., a video footage, dated 5/7/2025 of the East side of the Psychiatric (relating to mental illness) Acute Care Unit, was reviewed. The following was reviewed with Nurse Managers (NM) 1 and NM 2, and the Director of Security (DOS). The video footage indicated the following: At 7:55 a.m., Patient 2 (male patient) exited his (Patient 2) room and entered Patient 3's (female patient) room, located across the hall. No staff (registered nurses [RN] or licensed vocational nurses [LVNs]) were in the hallway at this time. At 7:57 a.m., Patient 2 and Patient 3 walked out of Patient 3's room. Patient 2 walked back to his (Patient 2) room across the hall. Patient 3 lingered in the hallway. At 7:58 a.m., Licensed Vocational Nurse (LVN) 1 went into Patient 2's room, then LVN 1 was seen on video surveillance talking to Patient 3 in the hallway. At 8:15 a.m., Registered Nurse (RN) 5 went into Patient 2's room. At 8:17 a.m., Registered Nurse (RN) 4 and Patient 2 walked out of Patient 2's room. Patient 2 was carrying his (Patient 2) belongings.

During an interview on 5/30/2025 at 3:30 p.m. with the Regulatory Specialist (RS), the RS stated she (RS) tried to interview Patient 3 about the alleged assault (an act that threatens physical harm to a person, whether or not actual harm is done) that took place on 5/7/2025, but Patient 3 became paranoid (a pattern of thinking where someone experiences intense, irrational distrust and suspicion of others) and asked her (RS) to leave. The RS also stated that she (RS) did not watch the video footage until 5/12/2025 (5 days after the incident occurred), when the state regulatory agency arrived to investigate the incident.

During an interview on 5/30/2025 at 3:30 p.m. with the Senior Director of Risk Management (SDRM), the SDRM stated the following: SDRM learned of the allegation by Patient 3 via an incident report submitted by Registered Nurse (RN) 5 on 5/7/2025, which was brought to her (SDRM) attention by the Director of Behavioral Health (DBH) ... DBH attempted to interview Patient 3 but Patient 3 refused to give any further details, other than a male entered her (Patient 3) room and covered her (Patient 3) mouth, which caused scratches to her (Patient 3) face. No attempts were made to watch the video footage. A formal root cause analysis (RCA, a systematic problem-solving method that aims to identify the underlying causes of events, problems, or failures) was not performed. The investigation could have been better. The investigation was not continued. There was not sufficient evidence at that point and the decision was made not to report the incident to the regulatory agency. SDRM stated that Patient 3 suffered an assault on 5/7/2027 and it should have been reported to the regulatory agency within 24 hours, for a prompt investigation and to identify any potential risk to the other patients.

During a review of Patient 3's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/01/2025, the H&P indicated Patient 3 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for suicidal ideations (thoughts of harming self).

During a review of Patient 3's "Clinical Note Nursing," dated 5/7/2025 at 1:54 p.m., the Clinical Note indicated the following: At 7:30 a.m., Patient 3 approached staff stating a male patient entered her (Patient 3) room and put his hand on her (Patient 3) face: Patient 3 appeared anxious, fearful but refused to give any more information ...Patient 3 observed to have a small, superficial scratches on her right upper lip and one (scratch) on the left lower lip ...

During a review of Patient 3's "Clinical Note Nursing," dated 5/7/2025 at 4:25 p.m., the Clinical Note indicated the following: "patient (Patient 3) is alert ...appears paranoid, watchful, looking over her shoulder, appears fearful when approached by staff; patient (Patient 3) stated a male patient came into her room at around 7:30 a.m., and put his hand on her face, causing two superficial scratches on her upper and lower lip ..."

During a review of the facility's policy and procedure (P&P) titled, "Reporting and Investigation of Incidents and Near Misses Policy," dated 12/21/2022, the P&P indicated the following. Definitions: Adverse event - Untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof.

During a review of the facility's policy and procedure (P&P) titled, "Adverse Event Reporting - California," dated 5/09/2023, the P&P indicated the following. The purpose of this policy is to facilitate quality improvement in the health care system by establishing a standard process for identifying and reporting adverse events that occur within the Hospitals and affected departments ...A. Identification of Reportable adverse Events ...Criminal Events including the following ...The death or serious injury of a patient or staff member from a physical assault (i.e. battery) that occurs within or on the grounds of a health care facility ....An adverse event or series of adverse events that cause the death or serious disability of a patient, personnel, or visitor ...When an adverse event occurs, staff must follow specific policies regarding documentation and notification processes. It is the responsibility of the assigned department (quality management, risk management, administration, etc.) to verify that the adverse event is reportable to the appropriate state agency or department ...Once the occurrence of an adverse event is confirmed the following shall be submitted to the State Agency (regulatory) ...An adverse event must be reported to the department no later than five (5) days after the adverse event has been detected, or if that event is an ongoing, urgent or emergent threat to the welfare, health, or safety of patients ...not later than 24 hours after the adverse event has been detected ...Investigation: An investigation into the cause of the event shall be under taken, using root cause analysis (RCA, a systematic problem-solving method that aims to identify the underlying causes of events, problems, or failures), intensified review or other approved investigative process. The investigation will be conducted for the purpose of the evaluation and improvement of the quality of care in the health care facility ...Quality Assessment and Performance Improvement (QAPI): The hospital must measure, analyze, and track adverse patient events. Performance improvement activities must track ...adverse events, analyze their causes, and implement preventative actions and mechanisms that include feedback and learning throughout the hospital ...

During a review of the facility's policy and procedure (P&P) titled, "Quality Assessment and Performance Improvement (QAPI) Program Plan," dated 5/28/2025, the P&P indicated the following ...Process improvement indicators will focus on improvement of health outcomes and prevention/reduction of medical error and will include: Measurement and tracking of medical errors/adverse patient events with analysis of causes. Implementation of preventative actions that include feedback and learning throughout the organization.

2. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/24/2025, the "H&P" indicated, Patient 1 was admitted to the facility's Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) with diagnoses including but not limited to subarachnoid hemorrhage (life-threatening type of stroke caused by bleeding into the space surrounding the brain), status post aneurysm coiling (a procedure to treat brain aneurysm [a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst]) on 1/24/2025 and uncontrolled hypertension (high blood pressure).

During a review of Patient 1's "Order Sheet (physician order sheet, orders written by physicians to direct care and treatment)," dated 1/30/2025, the physician order sheet indicated, to give nicardipine (medication to treat high blood pressure) intravenously (IV, administered into a vein) to keep systolic blood pressure (first number of blood pressure when the heart contracts and pushes out blood) less than 180 millimetres of mercury (mmHg, unit of measure) with initial (starting) rate of infusion (running) at 5 milligrams per hour (mg/hr, unit of measure), increment (an increase) of change at 2.5 mg/hr, frequency (how often) of increment of change every 15 minutes, maximum dose rate at 15 mg/hr. The physician order sheet also indicated, "discontinue order if rate remains at zero (0) for 23 hours."

During an interview on 5/27/2025 at 3:14 p.m. with the Intensive Care Unit (ICU) Registered Nurse (RN) 3, RN 3 stated the following: nurse should start IV nicardipine at 5mg/hr and titrate (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) per physician order. There should be a set of vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level) to coordinate with each titration.

During an interview on 5/28/2025 at 10:56 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: Patient 1 was found nonresponsive (does not react or move) on 2/6/2025 around 5:20 p.m. by RN 1, Patient 1's BP was 222/116 mmHg at 6 p.m. Patient 1 was sent to radiology (a department that utilizes various imaging techniques to diagnose and treat diseases) for STAT (a medical abbreviation for immediately or without delay) CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head scan. RN 2 received Patient 1 at change of shift at 7 p.m. and noted Patient 1 receiving IV nicardipine at 75 ml/hr (15mg/hr, maximum dose).

During a review of facility's medication dispensing (to supply) record titled, "All Transaction Activity Detail Report (dispensing record)," dated 2/6/2025, the dispensing record indicated, RN 1 retrieved one bag of IV nicardipine 40 mg per 200 milliliters (ml, unit of measure) for Patient 1 on 2/6/2025 at 6:22 p.m.
During a concurrent interview and record review on 5/28/2025 at 11:24 a.m. with the Stroke Coordinator (SC 1), Patient 1's "Medication Administration Record (MAR, record of medications given to patients)," dated from 1/31/2025 to 2/6/2025, was reviewed. The MAR indicated, Patient 1 received IV nicardipine infusion starting on 1/31/2025 with initial rate at 5 mg/hr and it was titrated to zero (0) on 2/1/2025 at 7:45 a.m. Nicardipine infusion rate was zero (0) from 2/2/2025 to 2/5/2025. The MAR also indicated, on 2/6/2025 at 7p.m. nicardipine was given at 15mg/hr with a comment indicating, "received patient (Patient 1) at this rate."

During the same interview on 5/28/2025 at 11:24 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: IV nicardipine was started for BP control and it was titrated to zero when the BP was within desired range. Patient 1 did not receive any nicardipine from 2/2/2025 to 2/5/2025. The nicardipine order should have been discontinued on 2/2/2025 by 6:45 a.m. since the last administration (2/1/2025) was over 23 hours. A new order was required to restart IV nicardipine. It was unknown what time and what initial rate nicardipine was restarted on 2/6/2025 because it was not documented. The medication was not titrated correctly.

During a concurrent interview and record review on 5/28/2025 at 11:30 a.m. with the Stroke Coordinator (SC 1), Patient 1's "Vital Signs" flowsheet (vital signs flowsheet), dated 2/6/2025, was reviewed. The vital signs flowsheet indicated the following:

-At 5:40 p.m.: Heart Rate (HR) = 80 beats per minute (bpm), BP = 204/98 mmHg;
-At 6 p.m.: HR = 94 bpm, BP = 222/116 mmHg;
-At 7 p.m.: temperature = 97.9 degrees Fahrenheit (F, unit of measure 100.4 degrees Fahrenheit equivalent to 38.0 degrees Celsius) taken orally, no HR, and no BP documented; and
-at 7:33 p.m.: HR = 70 bpm, BP = 67/40 mmHg.

During the same interview on 5/25/2025 at 11:30 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: there was no monitoring on Patient 1's blood pressure from 6 p.m. to 7:33 p.m. (1.5 hours) while Patient 1 was receiving IV nicardipine. Patient 1 became hypotensive (low blood pressure). Low blood pressure could affect perfusion (process of blood carrying oxygen and nutrients to the body tissues and organs) to the brain and contribute to no blood flow to brain.

During a concurrent interview and record review on 5/28/2025 at 11:40 a.m. with SC 1, Patient 1's "Nursing Documentation - Flowsheet (nursing assessment)," dated 2/6/2025, was reviewed. The "Nursing Documentation - Flowsheet" indicated, at 3 p.m., Patient 1's both pupils were PERRLA (Pupils equal, round, and reactive to light and accommodation, standard eye exam to check the health of eyes and the nervous system) with regular, round, size 3 mm, reaction was brisk (quick and full constriction) and consensual light reflex present; at 7 p.m. Patient 1's both pupils were not PERRLA with regular, round, size 5 mm, nonreactive. SC 1 stated it was a drastic change in neurological assessment (evaluation the function of the nervous system which comprise with brain, spinal cord and peripheral nerves). Patient 1's both pupils were blown (pupils were abnormally dilated, fixed and unresponsive to light) indicating there was no brain function, the brain was not perfusing.

During a review of Patient 1's "Physician Communication (physician communication note, documentation between nurse and physician communication regarding patient's condition and test result)" note, dated 2/6/2025, the physician communication note indicated, at 7:28 p.m., RN 2 informed physician (MD 2) that Patient 1 was hypotensive, MD 2 ordered to stop nicardipine and start Levophed (norepinephrine, medication used to raise blood pressure in patients with severe hypotension).

During a review of Patient 1's "Neurosurgery Progress Note (neurosurgeon note, physician progress note completed by neurosurgeon)," dated 2/7/2025, the neurosurgeon note indicated, "(Patient 1) had sudden loss of consciousness (unresponsive) yesterday. STAT CT showing large frontal (front part of the brain behind the forehead) hemorrhage (bleeding). Was started on Cardene (nicardipine, medication given intravenously [IV, directly into a vein) to lower blood pressure) for blood pressure management ... became bradycardic (low hear rate) and hypotensive (low blood pressure). Started pressor (medication to raise up the blood pressure) ... loss of brain stem reflexes (involuntary motor responses originating from the brainstem that control breathing, heart rate, and balance) were noted ... this morning remains unresponsive. No cough/gag reflex (a natural protective mechanism that prevents objects from entering the throat and potentially causing choking). No pupillary (relating pupil of the eye) or oculocephalic reflexes (a neurological reflex where the eyes move in the opposite direction of a rapid head rotation). No responses to painful stimuli. And not breathing over the ventilator (an appliance for artificial respiration). It was likely the patient has progressed to brain death (irreversible cessation of all brain function)."

During an interview on 5/29/2025 at 1:58 p.m. with the Director of Pharmacy (DIR 1), DIR 1 stated each IV titration medication order would include how much to start, how often to titrate, how much to titrate to achieve the set goal. Nurses needed to follow the medication order when titrating medications.

During an interview on 5/30/2025 at 11:27 a.m. with the ICU Director (DIR 2), DIR 2 stated the following: nurses must follow physician order when administering any titratable medication. Nurses could not change the medication dose, route, frequency without physician order. Nurses could not titrate nicardipine more frequent than every fifteen minutes per physician order. Nurses should monitor patient's vital signs throughout titration to evaluate his/her response to the medication.

During an interview on 5/30/2025 at 11:56 a.m. with the ICU Director (DIR 2), DIR 2 stated the following: the order of IV nicardipine showed as active on order set because no one discontinued the order as it should have been. This gave RN 1 access to retrieve the medication and administered to Patient 1.

During an interview on 5/30/2025 at 12 p.m. with DIR 2, DIR 2 state the following: the facility relied on nurses to check physician orders during shift report to discontinue any IV titration medication when it was not used over 23 hours. There was room for human error that nurses might forget to remove the order.

During an interview on 5/30/2025 at 12:39 p.m. with the ICU physician (MD 2), MD 2 stated the following: in ICU, the healthcare team would go over patient's titratable medications. The physician could discontinue a medication order, but he (MD 2) expected the nurses to discontinue any IV titratable medications when it was not in use. From the physician's end, he (MD 2) would not know if nurses were doing it (discontinuing the order) or not. It was possible for someone to overlook and not physically discontinue the order.

During an interview on 5/30/2025 at 2:03 p.m. with the Director of Pharmacy (DIR 1), DIR 1 stated the following: the intention to discontinue IV titratable medication after not being used over 23 hours was to avoid unnecessary medications. If the order remained active, nurses would have access to retrieve the medications. It relied on nursing critical thinking to discontinue the medications. Pharmacy did not have oversight. It was nursing responsibility. DIR 1 also stated the pharmacy was located in the basement and pharmacy staff were not there (in ICU) to check if the IV titratable medications have been stopped for over 23 hours (from the last administration time).

During an interview on 5/30/2025 at 4 p.m. with the Medication Safety Officer (MSO), MSO stated Patient 1's nicardipine incident was identified as a medication error because IV nicardipine was restarted despite it not used for more than 23 hours (last administration was 2/1/2025) and there was no new order to give IV nicardipine on 2/6/2025. The team performed a root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution), but it was identified as an isolated event.

During an interview on 5/30/2025 at 4:16 p.m. with the Senior Director for Risk Management (SDRM), SDRM stated the following: the facility did investigation and root cause analysis (RCA) involving nursing leadership, pharmacy, stroke team, risk management and quality department on 3/13/2025. The facility had identified there was lack of monitoring and documentation with the IV nicardipine administration, but it was only identified as an individual isolated event. There was no action taken with regards to IV titration medication being given beyond the order time. SDRM also stated the RCA was incomplete because the facility did not look further into IV nicardipine order to identify if there was any systemic problem.

During a review of Patient 26's "History and Physical (H&P)," dated 5/19/2025, the H&P indicated that Patient 26 was admitted to the facility with a diagnosis of status epilepticus (a continuous seizure [a temporary disruption of normal electrical activity in the brain that can cause changes in behavior, movement, or awareness] lasting five minutes or more, or recurrent seizures without recovery in between) and had to be intubated (a tube has been inserted into the patient's windpipe (trachea) through their mouth or nose to help them breathe).

During a review of Patient 26's medical record (MR) titled, "Order Sheet," dated 5/19/2025, the MR indicated that on 5/19/2025 at 5:58 a.m., the physician placed an order set for propofol (an intravenous medication used for sedation) to be given as a continuous infusion (titratable drip- slowly increasing the dose of a medicine by very small amounts over time) at initial rate of 10 micrograms per kilogram per minute (mcg/kg/min, measuring unit) .... Order comments indicated, " ...Discontinue Order if rate remains at zero [0] for 23 hours ..."

During a review of Patient 26's "Medical Administration Record (MAR)," dated from 5/19/2025 to 5/29/2025, the MAR indicated propofol infusion rate was 0 mg/hr on 5/26/2025 at 10:09 a.m. The MAR also indicated propofol infusion was restarted on 5/28/2025 at 1:59 a.m. (over 39 and 50 minutes beyond the last administration time).

During a review of Patient 27's History and Physical ( H&P, the most formal and complete assessment of the patient and the problem), dated 5/24/2025, the H&P indicated that Patient 27 was admitted to the facility with a diagnosis of subarachnoid hemorrhage (SAH, a type of stroke [a medical emergency that occurs when the brain's blood supply is disrupted, causing brain damage] caused by bleeding into the subarachnoid space, which is the area between the brain and the thin tissues [meninges] that cover it) and ruptured brain aneurysm (a medical condition where a weakened, bulging area in a blood vessel wall in the brain bursts, causing bleeding within the brain).

During a review of Patient 27's medical record (MR) titled, "Order Sheet," dated 5/24/2025, the MR indicated that on 5/24/2025 at 8:31 a.m., the physician placed an order set for nicardipine (Cardene I.V., a drip [infusion of a medication intended to lower blood pressure, BP]) to be given as a continuous infusion at a starting dose of 5 milligrams per hour (mg/hr, measuring unit) followed by increments of 2.5 mg/hr every 5 minutes until either reaching a maximal dose of 15 mg/hr or achieving the desired reduction in BP. Order comments indicated, " ...Discontinue Order if rate remains at zero [0] for 23 hours ..."

During a review of Patient 27's "Medical Administration Record (MAR)," dated from 5/23/2025 to 5/29/2025, the MAR indicated IV nicardipine was titrated down to zero (0) on 5/24/2025 at 3 p.m. The MAR also indicated IV nicardipine was restarted at 2.5 mg/hr on 5/25/2025 at 6:50 p.m. (almost 28 hours from last administration time on 5/24/2025 at 3 p.m.).

During a review of the facility's policy and procedure (P&P) titled, "Medication Errors Reporting," 9/2022, the P&P indicated, "to establish procedures regarding medication errors and encourage all hospital staff to report all medication error reporting as a tool to enhance patient safety and prevent future errors ... Definitions: A. Medication Error - any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer ... Type of medication errors ... d. Administration error - types of administration errors may include: wrong patient, dose, time, medication, route, rate ... and unauthorized dose given ... Medication Error Prevention Team. 1. The pharmacy will use the findings of the medication error prevention and reduction team to develop pharmacy systems and workflow processes designed to prevent medication errors ... All medication errors discovered, as per definition, are subject to a quality assurance review. 2. The primary purpose of the quality assurance review is to advance error prevention by analyzing the cause and contributing factors such as system or process failures."

During a review of the facility's policy and procedure (P&P) titled, " Reporting and Investigation Incidents and Near Misses Policy," dated 12/2022, the P&P indicated, "Incident and Near Misses Identification ... Role and Responsibilities ... Departmental file managers/directors are responsible for review and manage incident reports for their assigned areas of responsibility, which includes the following ... timely investigation of incident reports and documentation ... collaborating with other file managers/directors to complete all tasks associated with the investigation of an incident report ... evaluating for trends is the manager/director's area of responsibility, suggesting RCAs when applicable and recommending process improvement initiatives."

During a review of the facility's policy and procedure (P&P) titled, "Quality Assessment, Performance Improvement Plan (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital)," dated 3/2024, the P&P indicated, "Scope: As part of performance improvement, leaders (including governing body) will: 1. Set priorities (i.e. high volume, high risk, problem prone processes) for performance improvement and patient health outcomes in alignment with regulatory guidelines. 2. Identify frequency of dada collection for performance improvement. 3. Prioritize performance improvement in response to changes within the internal and external environment. 4. Proactively identify processes needing improvement to prevent medical errors. 5. Ensure methods (ie improvement tools) are implemented for identifying causes of variation, measuring performances of process improvement/deficiencies, and monitoring/sustaining processes ... Structure and Accountability ... 1. The Community Board (governing body [GB]) is responsible for assuring oversight of an ongoing quality improvement plan for patient safety, quality of care, organization-wide quality assessment, and contracted services. The GB is responsible for evaluating through periodic review and establishing clear expectation for quality of care and patient safety. The GB will ensure adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital's performance and determine the number of distinct improvement projects annually. The GB will delegate the development, implementation, and evaluation of QAPI to respective [the facility's] committees/ teams ... C. Performance Improvement Committee Functions ... Patient Safety Program ... integrates with all quality assessment and performance improvement activities. Cause analysis and proactive risk assessments, such as FMEA (failure mode effect analysis), will be utilized to assess actual and potential risk, failure, points of vulnerability, and prioritized areas for improvement based on impact to patient care outcomes ... D. Performance Improvement Model ... Process improvement indicators will focus on improvement of health outcomes and prevention/reduction of medical errors, and will include: a. measurement and tracking of medical errors/adverse event with analysis of causes b. implementation of preventative actions that include feedback and learning throughout the organization .... E. Aggregation and Analysis of Data ... 6. At minimum, the organization will collect data in the following areas ... Adverse Events, including (not limited to): significant medication errors; adverse drug reactions; medical errors (prevention and reduction of) ..."

During a review of the facility's policy and procedure (P&P) titled, "Titratable Medication Infusion Administration," dated 9/2021, the P&P indicated, "the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Titration medication orders ... the nurse must stay within the defined parameters of the medication orders ... Titratable medication documentation. 1. Titratable medication must be documented at the time of administration within MAR. 2. The goal of the titratable medication ... must be documented prior to initiating the titratable infusion and during each rate change. 3. Documentation will accurately reflect order changes and patient assessments ... Discontinuing a titratable medication. 1. A titratable infusion order will include the order detail that the infusion should be discontinued from the MAR when the patient has not received the medication for 23 hours or more."

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 12/2024, the P&P indicated, "Medication Administration should be performed by licensed medical staff according to manufacturer's prescribing information and in accordance with FDA (Food and Drug Administration, a government agency) regulations. Proper documentation, verifying patient specific information, medication security and compliance with specific drug policies should always be taken during medication administration ... Procedure ... Utilize the seven rights for administering medication: a. Right Patient b. Right Dose c. Right Time d. Right Route e. Right Drug f. Right to Refuse ... g. Right to be Educated ... Check all medications and IV solutions against eMAR (electronic medication administration record)/MAR ... access eMAR/MAR and/or physician order when administering medications at patient's bedside ... Documentation: 1. Medication administration should be documented immediately after administration, but no later than 1 hour after administration... Documentation should occur in the eMAR/MAR."

During a review of medication package insert (provide medication information and its use) for nicardipine, dated 10/2014, the medication package insert indicated, "Dosage and Administration ... Recommend Dosing ... Dosage for initiation of therapy in a patient not receiving oral nicardipine. Initiate therapy at 25 ml/hr (5mg/hr). If desire blood pressure reduction is not achieved at this dose, the infusion rate may be increased by 12.5ml/hr (2.5mg/hr) every five (5) minutes (for rapid titration) to 15 minutes (for gradual titration) up to a maximum of 75 ml/hr (15mg/hr), until desired blood pressure re

Based on interview and record review the facility failed to:

1. Ensure that for one of 41 sampled patients (Patient 27), nursing staff alternated the peripheral intravenous site (PIV, a small, short, flexible tube [catheter] inserted into a vein, usually in the hand or arm, to administer fluids, medications, or blood products), every 12 hours during continuous infusion of nicardipine (Cardene IV, a medication to treat chest pain or high blood pressure [BP]), through a catheter or needle that is continuously delivering the substance into the body, in accordance with the physician order.

This deficient practice had the potential for Patient 27 to develop complications associated with Nicardipine I.V. administration such as phlebitis (an inflammation of a vein), infiltration (when some of the fluid leaks out into the tissues under the skin where the tube has been put into the vein), or extravasation (the leakage of fluid or substances from a blood vessel or other enclosed space into the surrounding tissues, resulting in pain, swelling), which may go unrecognized and untreated, leading to tissue damage or necrosis (tissue death) and worsening of Patient 27's condition.

2. Ensure for one of 41 sampled patients (Patient 13), a Clinical Institute Withdrawal Assessment for Alcohol (CIWA, is a tool used to assess the severity of alcohol withdrawal symptoms) assessment was completed and documented per facility's policy regarding "Inpatient Management of Alcohol Withdrawal (a range of symptoms that can happen if someone stops or significantly reduce alcohol intake after long-term use)."

This deficient practice had the potential for delayed recognition of a patient's withdrawal symptoms (example: increased blood pressure, increased heart rate, and tremor [shakiness] of hands or other body parts), potentially resulting in inappropriate or insufficient treatment for Patient 13.

Findings:

1. During a review of Patient 27's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/24/2025, the H&P indicated that Patient 27 was admitted to the facility with a diagnosis of subarachnoid hemorrhage (SAH, a type of stroke [a medical emergency that occurs when the brain's blood supply is disrupted, causing brain damage] caused by bleeding into the subarachnoid space, which is the area between the brain and the thin tissues [meninges] that cover it) and ruptured brain aneurysm (a medical condition where a weakened, bulging area in a blood vessel wall in the brain bursts, causing bleeding within the brain).

During a review of Patient 27's medical record (MR) titled, "Order Sheet," dated 5/24/2025, the MR indicated that Patient 27 had an order for nicardipine drip (the drug [intended to lower blood pressure, BP] is given as a continuous infusion at a starting dose of 5 milligrams per hour [mg/hr, measuring unit] followed by increments of 2.5 mg/hr every 5 minutes until either reaching a maximal dose of 15 mg/hr or achieving the desired reduction in BP), placed on 5/24/2025.

During a review of Patient 27's Medication Administration Record (MAR), particularly administration of the continuous nicardipine drip (infusion) and the associated peripheral intravenous (PIV) site record, dated 5/25/2025 through 5/29/2025, the record indicated that on all occasions, Patient 27's peripheral intravenous site, was documented to be in the right antecubital (AC, the area of the inner elbow). This information was verified with the registered nurse (RN 6) during record review on 5/29/2025 at 2:56 p.m.

During an interview on 5/29/2025 at 3:11 p.m. with registered nurse (RN) 6, RN 6 stated the following: "We [nurses] document the peripheral IV site associated with the administration of a medication to enable tracing of any side effects related to the medication infusion." RN 6 also said that accurate documentation allowed (nurses) to identify and assess the site for complications such as phlebitis (inflammation of the vein) pain, swelling, or vesicants (substances that can cause tissue damage or blistering if extravasation occurs) which was essential for early detection and timely intervention to prevent tissue injury and ensure patient safety.

During a concurrent interview and record review on 5/29/2025 at 3:13 p.m. with Registered Nurse (RN) 6, Patient 27's "Order Sheet," was reviewed. The Order Sheet indicated that on 5/24/2025 [at 8:31 a.m.], an order for nicardipine continuous drip was placed with the following order comments: "Minimize peripheral venous infiltration by changing infusion site every 12 hours." RN 6 reviewed the Nicardipine IV order details and stated that the peripheral IV site should be alternated, in accordance with the physician order.

During a review of the nicardipine safety data sheet (SDS, a document that provides information about the potential hazards of a chemical or substance, along with guidance on how to handle, store, and dispose of it safely), dated 10/2014, the SDS indicated the following: "Administer Cardene (Nicardipine) I.V. by a central line or through a large peripheral vein. Change the infusion site every 12 hours if administered through peripheral vein to reduce the possibility of venous thrombosis, phlebitis, local irritation, swelling, extravasation, and the occurrence of vascular impairment. To minimize the risk of peripheral venous infiltration, change the site of the drug infusion every 12 hours."

2. During a review of Patient's 13's "History and Physical," dated 01/01/2025, the record indicated that Patient 13 arrived at the emergency department (ED) with complaints of left sided numbness, tingling, and weakness on left side of the body. The H&P also indicated alcoholism (an addiction to the consumption of alcoholic liquor) as an active problem, with a blood ethanol level (test that measures the amount of alcohol, or ethanol, in a patient's blood) of 0.11 grams per deciliter (gm/dL, a unit of measure; a blood alcohol level of 0.11 gm/dL is extremely high and would be associated with severe intoxication, potentially leading to coma or death)

During a review of Patient 13's "Order Plans," dated 01/01/2025 - 01/03/2025, the Order Plans indicated the following medical orders:
1. CIWA Assessment - NOW, on arrival to unit was ordered on 01/01/2025 at 4:24 a.m.
2. CIWA Assessment - every 6 hours while awake was ordered on 01/01/2025 at 10:24 a.m.

During a concurrent interview and record review on 05/28/2025 at 10:47 a.m. with Registered Nurse (RN) 12, Patient 13's medical record titled, "CIWA," dated 01/01/2025 - 01/02/2025, was reviewed. Patient 13's record did not indicate that a CIWA was completed on arrival to the telemetry unit (a specialized area where patients receive continuous monitoring of their vital signs, primarily cardiac rhythms and other physiological data), and the first CIWA was completed only on 01/02/2025 at 12 a.m. RN 12 stated that Patient 13 arrived at the Telemetry Unit on 01/01/2025 at 4:11 a.m.

During the same interview on 5/28/2025 at 10:47 a.m. with Registered Nurse (RN) 12, RN 12 said that the admitting nurse failed to follow the "CIWA Assessment" physician order. RN 12 stated the subsequent nurses who provided care to Patient 13 also failed to complete a CIWA on Patient 13. The patient's (Patient 13) blood alcohol level was 0.11 gm/dL indicating that the patient (Patient 13) may be alcoholic and may suffer from alcohol withdrawals symptoms (a set of symptoms that can develop if one stops or significantly reduce alcohol intake after long-term use). RN 12 added that it was important for nurses to complete the CIWA assessment so they (the nursing staff) could identify withdrawal symptoms, provide early intervention, and prevent further health complications.

During a review of the facility's Policy and Procedure (P&P) titled, "Inpatient Management of Alcohol Withdrawal," with last revised date of 2/14/2023, the P&P indicated the following:

"Alcohol Withdrawal Observations
a. The CIWA observation scale is used to monitor patients withdrawing from alcohol or at risk of withdrawing from alcohol.

Based on interview and record review, the facility failed to:

1. Formulate an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 41 sampled patients (Patient 26), to address Patient 26's admitting diagnosis of seizures (a sudden, temporary disturbance of the brain's normal electrical activity, often manifesting as changes in muscle tone, behavior, or awareness), in accordance with the facility's policy regarding care plans.

This deficient practice had the potential for Patient 26's care needs not to be met when no implementation of individualized care plan for seizures and safety precautions were embedded into Patient 26's treatment and care plan, which could result in complications such aspiration (the accidental inhalation of foreign materials, such as food, liquid, or stomach contents, into the lungs instead of the digestive tract [the mouth, stomach, and intestines]) leading to breathing problems, prolonged hospitalization, and/or even death.

2. Ensure one of 41 sampled patient's (Patient 13) plan of care regarding aspiration precaution (measures taken to prevent the accidental inhalation of food, liquid, or other substances into the lungs. These precautions are especially important for individuals with swallowing difficulties or other conditions that increase their risk of aspiration), was developed and implemented upon admission (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility's policy regarding care plans.

This deficient practice had the potential for serious complications such as aspiration pneumonia (lung infection that can be particularly dangerous for individuals with weakened immune systems or underlying health conditions), respiratory distress (difficulty breathing), prolonged hospitalization, and/or death.

3. Ensure one of 41 sampled patient's (Patient 20) plan of care regarding Chest Pain (often related to heart disease, its symptoms due to a heart attack or other heart condition includes Pressure, tightness, pain, squeezing or aching in the chest), was developed and implemented upon admission (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility's policy regarding care plans

This deficient practice had the potential to result in Patient 20's care needs and risks to not be identified and addressed in a timely manner, which may result in complications such as heart failure (a condition where the heart cannot pump enough blood to meet the body's needs), cardiac arrest (when the heart stops beating), and/or death.

4. Ensure one of 41 sampled patient's (Patient 22) plan of care regarding Fluid and Electrolyte Imbalance (maintaining a stable internal environment by regulating the amount of fluids and electrolytes [charged molecules] in the body. This balance is crucial for various bodily functions, including nerve and muscle activity, and blood pressure regulation), was developed and implemented upon admission (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility's policy regarding care plans.

This deficient practice had the potential for Patient 22's care needs and risks to not be identified and addressed in a timely manner which may result in complications such as dehydration (a condition that occurs when your body doesn't have enough fluid to function properly. It happens when you lose more fluids than you take in, which can disrupt various bodily functions like maintaining body temperature, transporting nutrients, and eliminating waste), prolonged recovery, and/or death.

Findings:

1. During a review of Patient 26's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/19/2025, the H&P indicated that Patient 26 was admitted to the facility with a diagnosis of status epilepticus (a continuous seizure [a sudden, temporary disturbance of the brain's normal electrical activity, often manifesting as changes in muscle tone, behavior, or awareness] lasting five minutes or more, or recurrent seizures without recovery in between) and had to be intubated (a tube has been inserted into the patient's windpipe [trachea] through their mouth or nose to help them breathe).

During a concurrent interview and record review on 5/29/2025 at 1:30 p.m. with registered nurse (RN) 6, Patient 26's electronic health records (EHR, digital version of paper chart), titled, "Care Plans," dated 5/18/2025 through 5/29/2025, were reviewed. Patient 26's Care Plans (documented strategies that outline patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers), had no developed care plan for "Seizures." RN 6 verified the lack of developed care plan for seizures for Patient 26 throughout the [Patient 26] admission stay at the facility [5/19/2025 through 5/29/2025].

During the same interview on 5/29/2025 at 1:30 p.m. with registered nurse (RN) 6, RN 6 said that based on Patient 26's admission diagnosis of seizures, a care plan for seizures should have been developed and maintained for Patient 26. RN 6 reviewed Patient 26's EHR in an attempt to locate nursing documentation of maintaining seizure precautions (safety measures taken before and during a seizure to prevent injury and ensure a person's well-being) but said that there was no nursing documentation of seizure precautions anywhere in Patient 26's EHR. RN 6 then reviewed the available care plan for seizures and stated that seizure precautions (padded siderails, suction, oxygen at bedside) can be documented in the intervention section of the care plan once it's initiated.

During an interview on 5/30/2025 at 4:12 p.m. with registered nurse (RN) 6, RN 6 stated that a care plan was developed based on the patient's identified needs and problems, and it should include the establishment of specific goals to guide the development of appropriate interventions aimed at meeting the patient's individual needs and achieving the desired outcomes.

During a review of the facility's policy and procedure (P&P) titled, "Standards of Nursing Practice Critical Care Department (Intensive Care Unit)," dated 2/2025, the P&P indicated that "nursing diagnoses and care issues are derived from the assessment data with the patient ...and are prioritized and documented in a manner that facilitates prioritizing outcomes and developing or modifying the plan ...Outcomes are derived from actual or potential diagnoses and care issues, and shall be identified on the care plan by documentation of measurable goals within approximately 24 hours of admission to recognize and incorporate unique patient-centered values and care needs. Outcomes provide direction for continuity of care, and the plan establishes priorities for care .... Care is delivered in a manner that promotes patient safety..."

2. During a review of Patient's 13's "History and Physical," dated 01/01/2025, the H&P indicated that Patient 13 arrived at the emergency department (ED) complaining of left sided numbness, tingling and weakness on left side of body. The H&P also indicated Patient 13 had a past medical history of alcohol withdrawals (Symptoms that can develop if one stops or significantly reduce alcohol intake after long-term use) and stroke (occurs when blood flow to the brain is disrupted, either by a blockage or a burst blood vessel).

During a review of Patient's 13 "Order," dated 01/01/2025 - 01/03/2025, the record indicated the following medical orders:
"Continuous Order, Aspiration Precautions (measures taken to prevent the accidental entry of food, liquid, or other foreign substances into the lungs), was ordered on 01/01/2025 at 8:04 a.m.

During a concurrent interview and record review on 05/28/2025 at 10:47 p.m. with Registered Nurse (RN) 12, Patient 13's medical record titled, "Plan" undated, was reviewed. The record indicated that a plan of care for Aspiration Precaution was not initiated upon admission. RN 12 stated that, admitting nurse should have initiated a plan of care for aspiration precaution. RN 12 further said a plan of care was important because it provided the care team a framework for organizing care, prioritizing needs, promoting communication, and documenting interventions to help meet patient care goals.

During a review of the facility's Policy and Procedure titled, "Standard of Nursing Practice" (Policy No.: 8720.405), with last revised date of 02/27/2025, the P&P indicated the following:

The Standards of Practice describe a competent level of nursing care according to the critical thinking model known as the nursing process.
1. Assessment: The RN collects pertinent data and information relative the patient's health/condition.
2. Diagnosis: The RN analyzes assessment data to determine actual or potential diagnoses, problems, and issues.
3. Outcomes Identification: The RN identifies expected outcomes for a care plan individualized to patient situation/medical conditions.
4. Planning: The RN develops a prioritized care plan that prescribes strategies to attain expected, measurable outcomes.
5. Implementation: The RN implements the identified care plan.
a. Coordination of Care: The RN coordinates care delivery.
b. Health Teaching and Health Promotion: The RN uses approaches and strategies to promote health, healing and a safe environment.

3. During a review of Patient's 20's "History and Physical," dated 05/24/2025, the H&P indicated that Patient 20 arrived at the facility with complaints of chest pain for 1 day and weakness. Patient 20 had history of hypertension (high blood pressure), diabetes mellitus type 2 (occurs when the body either doesn't produce enough insulin [regulates blood glucose or blood sugar by allowing cells to absorb glucose from the bloodstream for energy. Insulin also influences the metabolism of fats and proteins] or can't use insulin effectively, leading to high blood sugar levels) and anxiety orders (mental health conditions characterized by excessive and persistent worry, fear, and anxiety).

During a concurrent interview and record review on 05/28/2025 at 1:55 p.m. with Registered Nurse (RN) 12, Patient 20's medical record titled, "Plan," undated, was reviewed. The record indicated that a plan of care for Chest Pain was not initiated upon admission. RN 12 stated that, admitting nurse should have initiated a plan of care for Chest Pain. RN 12 said a plan of care was important because it identifies patient care progression toward goal outcome.

During a review of the facility's Policy and Procedure titled, "Standard of Nursing Practice" (Policy No.: 8720.405), with last revised date of 02/27/2025, the P&P indicated the following:

The Standards of Practice describe a competent level of nursing care according to the critical thinking model known as the nursing process.
1. Assessment: The RN collects pertinent data and information relative the patient's health/condition.
2. Diagnosis: The RN analyzes assessment data to determine actual or potential diagnoses, problems, and issues.
3. Outcomes Identification: The RN identifies expected outcomes for a care plan individualized to patient situation/medical conditions.
4. Planning: The RN develops a prioritized care plan that prescribes strategies to attain expected, measurable outcomes.
5. Implementation: The RN implements the identified care plan.
a. Coordination of Care: The RN coordinates care delivery.
b. Health Teaching and Health Promotion: The RN uses approaches and strategies to promote health, healing and a safe environment.

4. During a review of Patient's 22's "History and Physical," dated 05/10/2025, the H&P indicated that Patient 22 arrived at the facility with complaints of hypotension (low blood pressure). The H&P also indicated that Patient 22 had multiple comorbidities (the presence of two or more medical conditions) including end-stage kidney disease (a severe form of kidney failure where the kidneys can no longer adequately filter waste and fluids from the blood), on hemodialysis (is a treatment that cleans your blood when your kidneys can't do their job well enough, often due to kidney failure), diabetes mellitus type 2 (occurs when the body either doesn't produce enough insulin [regulates blood glucose or blood sugar by allowing cells to absorb glucose from the bloodstream for energy. Insulin also influences the metabolism of fats and proteins] or can't use insulin effectively, leading to high blood sugar levels), dysphagia (difficulty swallowing), on tube feedings (involves delivering nutrients directly into the digestive system via a tube). The H&P also indicated that Patient 22 was a resident of a skilled nursing facility (a facility that provides specialized care and rehabilitation for individuals who need a higher level of medical care than can be provided at home or in an assisted living setting).

During a concurrent interview and record review on 05/28/2025 at 2:48 p.m. with Registered Nurse (RN) 12, Patient 22's medical record titled, "Plan," undated, was reviewed. The record indicated that a plan of care for Fluid and Electrolyte Imbalance (maintaining a stable internal environment by regulating the amount of fluids and electrolytes [charged molecules] in the body. This balance is crucial for various bodily functions, including nerve and muscle activity, and blood pressure regulation), was not initiated upon admission. RN 12 stated that, admitting nurse should have initiated a plan of care for Fluid and Electrolyte Imbalance. RN 12 further stated that a plan of care was important because it identified patient care progression toward goal outcome.

During a review of the facility's Policy and Procedure titled, "Standard of Nursing Practice" (Policy No.: 8720.405), with last revised date of 02/27/2025, the P&P indicated the following:

The Standards of Practice describe a competent level of nursing care according to the critical thinking model known as the nursing process.
1. Assessment: The RN collects pertinent data and information relative the patient's health/condition.
2. Diagnosis: The RN analyzes assessment data to determine actual or potential diagnoses, problems, and issues.
3. Outcomes Identification: The RN identifies expected outcomes for a care plan individualized to patient situation/medical conditions.
4. Planning: The RN develops a prioritized care plan that prescribes strategies to attain expected, measurable outcomes.
5. Implementation: The RN implements the identified care plan.
a. Coordination of Care: The RN coordinates care delivery.
b. Health Teaching and Health Promotion: The RN uses approaches and strategies to promote health, healing and a safe environment.

Based on interview and record review, the facility failed to:

1. Ensure that one of 41 sampled patients (Patient 26), had the RASS (the Richmond Agitation Sedation Scale, is a tool designed to assess the level of alertness and agitated behavior in critically ill patients) documented during the initiation of Precedex infusion (dexmedetomidine, a sedative medication used for sedation in intensive care patients), in accordance with the facility's policy regarding titratable medications administration (the administration of a medication over time, starting with the least dosage required for improving the medical condition).

This deficient practice had the potential for Patient 26 to experience inadequate sedation (drowsiness or sleep) management, including over-sedation or under-sedation, which could lead to increased risk of adverse events such as delayed neurological assessment, respiratory depression (inadequate ventilation, causing a low breathing rate), and unrecognized agitation (a state of extreme restlessness or uneasiness), thereby compromising Patient 26's safety.

2. Monitor nineteen (19) of 19 sampled patients (Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39) in the Psychiatric (relating to mental or behavior illness) Acute Care (PAC) unit, every 15 minutes, in accordance with the facility's policy and procedure regarding managing patients with high risk behaviors (actions that significantly increase the potential for harm, injury, or negative consequences, impacting both the individual and potentially others) who are admitted to the Behavioral Health Unit (or PAC unit).

This deficient practice placed 19 patients' safety at risk such as self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence.

3. Ensure its nursing staff communicated and reported critical test results (a test or examination that always requires rapid communication of the results) for one of 41 sampled patients (Patient 1), in accordance with the facility's policy and procedure regarding critical test result reporting, when there was no evidence that Patient 1's CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) scans were reported to a physician within required timeframe (within 60 minutes) on 2/6/2025.

This deficient practice had the potential to delay for Patient 1's physician to evaluate Patient 1's condition and determine appropriate interventions.

4. Ensure its nursing staff performed a National Institute of Health Stroke Scale (NIHSS, a clinical assessment tool used to measure a patient's neurological status after a stroke to quantify the severity of stroke-related deficits and monitor changes in a patient's condition over time) assessment, when Stroke Alert (a protocol the facility developed in response to patient experiencing acute [new onset] stroke symptoms) was activated for one of 41 sampled patients (Patient 1) on 2/6/2025, in accordance with the facility's policy and procedure regarding r stroke protocol.

This deficient practice resulted in Patient 1's severity of stroke not evaluated at the time when stroke alert was called, and had the potential to result in delayed identification and reporting of the severity of stroke Patient 1 was experiencing, to the physician and the stroke team, thus causing delay in care and treatment.

Findings:

1. During a review of Patient 26's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/19/2025, the H&P indicated that Patient 26 was admitted to the facility with a diagnosis of status epilepticus (a continuous seizure [a sudden, temporary disturbance of the brain's normal electrical activity, often manifesting as changes in muscle tone, behavior, or awareness] lasting five minutes or more, or recurrent seizures without recovery in between) and had to be intubated (a tube has been inserted into the patient's windpipe (trachea) through their mouth or nose to help them breathe).

During a review of Patient 26's medical record (MR) titled, "Order Sheet," dated 5/26/2025, the MR indicated that on 5/26/2025 at 10:09 a.m., the physician placed an order set for Precedex infusion (dexmedetomidine, a sedative medication used for sedation in intensive care patients) to be given as a continuous infusion (titratable drip- slowly increasing the dose of a medicine by very small amounts over time) at initial rate of 0.2 micrograms (mcg, measuring unit) micrograms to titrate up and down by 0.1 mcg every 10 minutes. Order comments indicated the following details:
"Monitor RASS score (the Richmond Agitation Sedation Scale, is a tool designed to assess the level of alertness and agitated behavior. A score of 0 signifies alert and calm, positive scores represent increasing levels of agitation, and negative scores indicate varying levels of sedation, from drowsiness to unarousable) and titrate to achieve the goal of a RASS of 0 to -2 ...
-RASS score levels:
0: Alert and Calm: Patient is alert, awake, and calm.
-1: Drowsy: Not fully alert but has sustained awakening (eye opening/eye contact) to voice (greater than 10 seconds).
-2: Light Sedation: Briefly awakens to voice with eye contact (less than 10 seconds)].

During a concurrent interview and record review on 5/29/2025 at 3:46 p.m. with registered nurse (RN) 6, Patient 26's "Medication Administration Record (MAR), dated 5/26/2025, for Precedex administration on 5/26/2025, was reviewed. The MAR indicated that the Precedex drip was initiated on 5/25/2025 at 10:09 a.m. at a rate of 0.2 mcg/kg/hr (micrograms per kilogram per hour, measuring unit). It was titrated upward every 10 minutes to reach 0.8 mcg/kg/hr by 11::10 a.m., then titrated down to 0.7 mcg/kg/hr at 11:20 a.m., and further titrated down to 0/6 mcg/kg/hr. The RASS score was not documented during the titration of Precedex from 10:09 a.m. through 12:00 p.m.

During the same interview on 5/29/2025 at 3:46 p.m. with registered nurse (RN) 6, RN 6 stated that when titrating Precedex, the RASS score should be assessed and monitored. RN 6 stated the RASS score indicated the patient's sedation level and without assessing it, there was no way to know the patient met the goal of a RASS of 0 to -2, as indicated in the physician order.

During a review of the facility's policy and procedure (P&P) titled, "Titratable Medication Infusion Administration," dated 9/2/2021, the P&P indicated the following:
-"Titration orders- are defined as those in which the medication dose is either progressively increased or decreased in response to the patient's status. D. Titratable medication documentation:
1. Titratable medications must be documented at the time of administration within the MAR.
2. The goal of the titratable medication (i.e. blood pressure, heart rate, RASS, pain, etc.) must be documented prior to initiating the titratable infusion and during each rate change.

3. During a review on 5/28/2025 at 10:25 a.m., a Video footage, dated 5/7/2025 of the East side of the Psychiatric (relating to mental illness) Acute Care Unit, was reviewed. The following was reviewed on video surveillance with Nurse Managers (NM) 1 and NM 2. The video footage indicated that on 5/7/2025 at 4:15 a.m., Licensed Vocational Nurse (LVN) 2 was not seen in the hallway conducting rounds (a systematic process where a healthcare team member checks on a patient regularly) on Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39. NM 1 stated that rounds should be conducted every 15 minutes by going into patient rooms and checking for a safe environment, patients' condition, behavior, and whether the patient was breathing or sleeping. NM 1 stated that the round on 5/7/2025 at 4:15 a.m., was missed. NM 1 said that LVN 2 documented that she (LVN 2) had conducted rounding at 4:15 a.m., and that the documentation was falsified (false or incorrect). NM 1 stated not rounding every 15 minutes placed patients' safety at risk.

During a review of a document titled, "Patient Observation Checklist - Psych Acute Care - East," dated 5/7/2025, the document indicated Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39 were on the unit. At 4:15 a.m., Patients 12 and 30 were in their room, awake. At 4:15 a.m., Patients 2, 3, 8, 9, 10, 11, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, and 39 were in their room, asleep. NM 1 verified that this documentation was false and that the monitoring did not occur.

During a review of Patient 2's Behavioral History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/19/2025, the H&P indicated the following: Patient 2 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for Grave Disability (a person who is unable to care for their basic needs due to a mental health disorder).

During a review of Patient 3's Behavior History and Physical (H&P), dated 5/01/2025, the H&P indicated Patient 3 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for suicidal ideations (thoughts of harming self).

During a review of Patient 8's History and Physical (H&P), dated 4/19/2025, the H&P indicated Patient 8 was admitted to the facility on a 5150 hold for grave disability.

During a review of Patient 9's Behavioral History and Physical (H&P), dated 4/29/2025, the H&P indicated Patient 9 was admitted to the facility on a 5150 hold for danger to self and danger to others.

During a review of Patient 10's Behavioral History and Physical (H&P), dated 5/5/2025, the H&P indicated Patient 10 was admitted to the facility on a 5150 hold for danger to self. Patient 10 had a history of major depression (serious mental disorder characterized by persistent feelings of sadness, loss of interest in activities, and a range of other symptoms that interfere with daily life).

During a review of Patient 11's Behavioral History and Physical (H&P), dated 4/4/2025, the H&P indicated Patient 11 was admitted to the facility on a 5150 hold for grave disability.

During a review of Patient 12's Behavioral History and Physical (H&P), dated 5/2/2025, the H&P indicated Patient 12 was admitted to the facility on a 5150 hold for grave disability.

During a review of Patient 28's Behavioral History and Physical (H&P), dated 4/17/2025, the H&P indicated Patient 28 was admitted to the facility on a 5150 hold for grave disability.

During a review of Patient 29's Behavioral History and Physical (H&P), dated 5/3/2025, the H&P indicated Patient 29 was admitted to the facility on a 5150 hold for grave disability.

During a review of Patient 30's Behavioral History and Physical (H&P), dated 4/30/2025, the H&P indicated Patient 30 was admitted to the facility on a 5150 hold for grave disability and danger to self.

During a review of Patient 31's Behavioral History and Physical (H&P), dated 5/6/2025, the H&P indicated Patient 31 was admitted to the facility on a 5150 hold for danger to self.

During a review of Patient 32's Behavioral History and Physical (H&P), dated 5/04/2025, the H&P indicated Patient 32 was admitted to the facility because of delusions (persistent, false beliefs held with a strong conviction despite evidence to the contrary) and uncontrolled behavior.

During a review of Patient 33's History and Physical (H&P), dated 5/03/2025, the H&P indicated Patient 33 was admitted to the facility on a 5150 hold for being gravely disabled. Patient 33's diagnosis included psychosis (disconnection from reality) and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly).

During a review of Patient 34's History and Physical (H&P), dated 3/22/2025, the H&P indicated Patient 34 was admitted to the facility on a 5150 hold for grave disability. Patient 34's diagnosis included schizophrenia.

During a review of Patient 35's Behavioral History and Physical (H&P), dated 5/05/2025, the H&P indicated Patient 35 was admitted to the facility on a 5150 hold for being a danger to self (thoughts of harming self).

During a review of Patient 36's History and Physical (H&P), dated 5/04/2025, the H&P indicated Patient 36 was admitted to the facility for psychosis and suicidal ideations.

During a review of Patient 37's Behavioral History and Physical (H&P), dated 4/29/2025, the H&P indicated Patient 37 was admitted to the facility on a 5150 hold for being a danger to self. Patient 37's diagnosis included schizophrenia.

During a review of Patient 38's Behavioral History and Physical (H&P), dated 1/24/2025, the H&P indicated Patient 38 was admitted to the facility for aggressive behavior and suicidal ideations. Patient 38 was on a 5150 hold for danger to self.

During a review of Patient 39's History and Physical (H&P), dated 3/15/2025, the H&P indicated Patient 39 was admitted to the facility for being agitated and aggressive and on a 5150 hold for being a danger to others and grave disability.

During a review of the facility's policy and procedure (P&P) titled, "Management of High-Risk Behaviors," dated 09/27/2021, the P&P indicated the following: All patients treated in Behavior Health & Recovery are monitored at 15-minute intervals continuously throughout the day to minimize the occurrence of high-risk behaviors. These safety monitors are to include, at a minimum:
1. Observation of patient's general physical condition.
2. Location of patient
3. Patient activity at that time the monitoring takes place.

3. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/24/2025, the "H&P" indicated, Patient 1 was admitted to the facility's Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) with diagnoses including but not limited to subarachnoid hemorrhage (life-threatening type of stroke caused by bleeding into the space surrounding the brain), status post aneurysm coiling (a procedure to treat brain aneurysm [a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst]) on 1/24/2025 and uncontrolled hypertension (high blood pressure).

During an interview on 5/28/2025 at 10:56 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: Patient 1 was found nonresponsive (does not react or move) on 2/6/2025 around 5:20 p.m. by RN 1, Patient 1's BP was 222/116 mmHg at 6 p.m. Patient 1 was sent to radiology (a department that utilizes various imaging techniques to diagnose and treat diseases) for STAT (a medical abbreviation for immediately or without delay) CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head scan.

During a review of Patient 1's Physician Orders, dated 2/6/2025. The Physician Orders indicated, a STAT CT Brain same as CT head without contrast (a special dye to enhance the visibility of specific areas of the body such as blood vessels and organs on the scan image) was ordered on 2/6/2025 at 5:44 p.m. with reason for subarachnoid hemorrhage. The Physician Orders also indicated, a STAT CT Angio (CT angiography, a medical imaging technique that uses a CT scan along with a contrast dye to visualize blood vessels) Head/Neck with contrast was ordered on 2/6/2025 at 5:45 p.m. with reason for subarachnoid hemorrhage.

During a concurrent interview and record review on 5/28/2025 at 10:42 a.m. with SC 1, Patient 1's CT scan report of "CT Brain without contrast (CT scan report 1)," dated 2/6/2025, was reviewed. The CT scan report 1 indicated, "Evidence of large heterogeneous (composed of different kinds) intracerebral (inside the brain) hematoma (collection of clotted blood outside blood vessel often due to injury or bleeding) in the frontal midline (medial surface of frontal lobe [front part of the brain behind the forehead]), measuring approximately 5.0 x 5.0 x 4.5 centimeters (cm, unit of measure) in dimension, with also evidence of moderate subarachnoid hemorrhage in the midline vertex (the highest point) area and possible hemorrhagic infarction (region of brain tissue that has died due to lack of blood supply) in the frontal lobes bilaterally..." The CT scan report 1 also indicated the result was read to RN 1 on 2/6/2025 at 6:28 p.m.

During the same interview on 5/28/2025 at 10:42 a.m. with SC 1, SC 1 stated the following: this result was a critical test result (a test or examination that always requires rapid communication of the results). RN 1 should have reported to neurosurgeon (medical doctor specializing in the diagnosis and treatment affecting brain, spinal cord, and nerves). Neurosurgeon could then determine what to do next based on the CT scan report.

During a concurrent interview and record review on 5/28/2025 at 10:48 a.m. with SC 1, Patient 1's CT scan report of "CT Angio Head/Neck with contrast (CT scan report 2)," dated 2/6/2025, was reviewed. The CT scan report 2 indicated, "Strong suggestion of fusiform aneurysm arising from the anterior communicating artery measuring approximately 1.3 x 5 millimeter (mm, unit of measure), directed superiorly ..." The CT scan report 2 also indicated, the result was read to RN 2 on 2/6/2025 at 6:56 p.m.

During the same interview on 5/28/2025 at 10:48 a.m. with SC 1, SC 1 stated the following: this result was a critical test result. RN 2 should have reported to neurosurgeon. Neurosurgeon could then decide to pass on to the neuro-interventionist (medical physician specialized in training in the use of minimal invasive, image-guided techniques to treat complex conditions of the brain, neck and spine) for further intervention or not.

During a concurrent interview and record review on 5/28/2025 at 10:54 a.m. with SC 1, Patient 1's "Communication Physician (documentation by nursing to indicate communication with physician)" note, dated 2/6/2025, was reviewed. The "Communicate Physician" note, indicated there was no documentation regarding RN 1 and RN 2 reporting both CT scan reports (CT scan report 1 and 2) to any physician. SC 1 stated the following: the nursing staff receiving the critical result must contact the neurosurgeon for the critical CT scan results within 60 minutes. There was no documentation indicating RN 1 and RN 2 had reported the critical CT scan results to the physician.

During a concurrent interview and record review on 5/28/2025 at 11:11 a.m. with SC 1, Patient 1's "Critical Care Progress Note (physician note, progress note completed by an intensivist [physician who provides special care for critically ill patients typically in ICU)," dated 2/7/2025, was reviewed. The "Intensivist note," indicated, "2/7 abruptly became unconscious (unable to respond to people and activities) last night, CT brain with large frontal intraparenchymal hemorrhage (bleeding within the brain tissue), neuro exam (an assessment of a person's nervous system, including the brain, spinal cord, and nerves) very poor, hypothermic (dangerously low body temperature). I discussed with family last night." SC 1 stated the physician note did not indicate what time the intensivist received or reviewed the CT scan reports.

During a concurrent interview and record review on 5/28/2025 at 11:13 a.m. with SC 1, Patient 1's "Neurosurgery Progress Note (neurosurgeon note, physician progress note completed by neurosurgeon)," dated 2/7/2025, was reviewed. The neurosurgeon note indicated, "(Patient 1) had sudden loss of conscious (unresponsive) yesterday. STAT CT showing large frontal hemorrhage. Was started on Cardene (nicardipine, medication given intravenously [IV, directly into a vein) to lower blood pressure) for blood pressure management ... became bradycardic (low heart rate) and hypotensive (low blood pressure). Started pressor (medication to raise up the blood pressure) ... loss of brain stem reflexes (involuntary motor responses originating from the brainstem that control breathing, heart rate, and balance) were noted ... this morning remains unresponsive. No cough/ gag reflex (a natural protective mechanism that prevents objects from entering the throat and potentially causing choking). No pupillary (relating pupil of the eye) or oculocephalic reflexes (a neurological reflex where the eyes move in the opposite direction of a rapid head rotation). No responses to painful stimuli. And not breathing over the ventilator (an appliance for artificial respiration). It was likely the patient has progressed to brain death (irreversible cessation of all brain function). Surgical intervention unfortunately will not change the prognosis. Recommend conclusive brain death examination when appropriate." SC 1 stated the physician note did not indicate what time the neurosurgeon received or reviewed the CT scan report.

During an interview on 5/30/2025 at 12:15 p.m. with the ICU Director (DIR 2), DIR 2 stated the following: nurses should report any critical result to the physician and document the communication per facility's policy so it could establish a timeline and track if interventions provided were done in a timely manner. RN 1 and RN 2 did a lot of work for Patient 1 on 2/6/2025, but the documentation did not reflect those. The intensivist (MD 1) read the CT scan reports of the bleeding and discussed with the team. However, there was nothing documented during that time frame.

During a review of the facility's policy and procedure (P&P) titled, "Critical Tests and Critical Results Reporting Policy," dated 8/2023, the P&P indicated, "to standardize the process when critical results of tests fall significantly outside the normal range and may indicate a life-threatening situation. The objective of this policy is to provide guidelines for management and reporting of critical tests and critical results of test to provide patients with prompt treatment ... Policy ... B. Reporting/Documenting of Results of Tests: a. for Critical Tests only - once results are available/ validated they are communicated to the ordering provider/ designee or Registered Nurse ... C. Receiving Results/ Reports: 1. Registered Nurse for Inpatients ... a. communicate to ordering provider/designee within 60 minutes and documents the following: i. provider notified (including full name and title), ii. Date/time called, iii. Two patient identifiers confirmed with provider/designee (patient name and date of birth may be used), iv: critical test reported, v. read-back completed, vi: actions taken ... D. Reporting time frames: 1. Critical results of test measurement parameters - the maximum length of time between the availability of critical result(s) and reporting of such critical result(s) to the ordering provider/designee should not exceed 60 minutes."

4. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/24/2025, the "H&P" indicated, Patient 1 was admitted to the facility's Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) with diagnoses including but not limited to subarachnoid hemorrhage (life-threatening type of stroke caused by bleeding into the space surrounding the brain), status post aneurysm coiling (a procedure to treat brain aneurysm [a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst]) on 1/24/2025 and uncontrolled hypertension (high blood pressure).

During an interview on 5/27/2025 at 3:19 p.m. with the Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) Registered Nurse (RN) 3, RN 3 stated the following: nurse would activate stroke alert (a protocol the facility developed in response to patient experiencing acute [new onset] stroke symptoms) when a patient experience stroke-like symptoms such as facial drooping (sagging appearance of one side of the face due to weakness or paralysis of the facial muscles), facial asymmetry (condition where the left and right sides of the face are not identical, resulting in an uneven appearance), and slurred speech. Once stroke alert was activated, nurse would perform National Institutes of Health Stroke Scale (NIHSS, a clinical assessment tool used to measure a patient's neurological status after a stroke to quantify the severity of stroke-related deficits and monitor changes in a patient's condition over time) assessment right away with the neurological assessment. All ICU nurses were NIHSS certified and able to perform the NIHSS assessment.

During an interview on 5/28/2025 at 10:56 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: Patient 1 was found nonresponsive (does not react or move) on 2/6/2025 around 5:20 p.m. by RN 1, Patient 1's BP was 222/116 milliliter of mercury (mmHg, unit of measure) at 6 p.m. Patient 1 was sent to radiology (a department that utilizes various imaging techniques to diagnose and treat diseases) for STAT (a medical abbreviation for immediately or without delay) CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head scan.

During a review of the facility's "Stroke Alert Log," dated 2/2025, the "Stroke Alert Log" indicated, Stroke Alert was called on 2/6/2025 at 5:47 p.m. for Patient 1.

During a concurrent interview and record review on 5/28/2025 at 11:40 a.m. with SC 1, Patient 1's "Nursing Documentation - Flowsheet," dated 2/6/2025 from 7 a.m. to 7 p.m. was reviewed. The "Nursing Documentation - Flowsheet" indicated, at 7 a.m., Patient 1's NIH stroke score (scoring from NIHSS assessment, a score ranging from zero to 42, where higher scores indicate more severe deficits) was 4 and at 7 p.m., Patient 1's NIH stroke score became 30. SC 1 stated no NIH stroke score was documented after stroke alert was called.

During a review of Patient 1's "Neurosurgery Progress Note (neurosurgeon note, physician progress note completed by neurosurgeon)," dated 2/7/2025, the neurosurgeon note indicated, "(Patient 1) had sudden loss of consciousness (unresponsive) yesterday. STAT CT showing large frontal (front part of the brain behind the forehead) hemorrhage (bleeding). Was started on Cardene (nicardipine, medication given intravenously [IV, directly into a vein) to lower blood pressure) for blood pressure management ... became bradycardic (low hear rate) and hypotensive (low blood pressure). Started pressor (medication to raise up the blood pressure) ... loss of brain stem reflexes (involuntary motor responses originating from the brainstem that control breathing, heart rate, and balance) were noted ... this morning remains unresponsive. No cough/gag reflex (a natural protective mechanism that prevents objects from entering the throat and potentially causing choking). No pupillary (relating pupil of the eye) or oculocephalic reflexes (a neurological reflex where the eyes move in the opposite direction of a rapid head rotation). No responses to painful stimuli. And not breathing over the ventilator (an appliance for artificial respiration). It was likely the patient (Patient 1) has progressed to brain death (irreversible cessation of all brain function).

During an interview on 5/30/2025 at 12:21 p.m. with the Stroke Navigator (SN 2), SN 2 stated the following: nurse should perform the NIHSS assessment to evaluate the severity of the stroke. It could help to see what deficit the patient experiencing and to determine what type of treatment patient would need. The higher the NIH stroke score, the worse is the stroke.

During a review of the facility's policy and procedure (P&P) titled, "In-Patient Stroke Alert/Stroke Alert Team," dated 9/2024, the P&P indicated, "the purpose of this policy is to establish a procedure for the provision of timely and effective care for [the facility] in-patients exhibiting acute stroke symptoms ... Stroke Alert Process for In-patients: 1. When a hospital in-patient exhibits acute stroke symptoms, the Registered Nurse will initiate the Rapid Response Team (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) ... the Rapid Response Team will verify acute stroke symptoms and initiate a stroke alert on patient exhibiting stroke symptoms with an onset within 24 hours ... Stroke Alert Response ... Roles and Responsibilities: 1. Stroke Program Manager/Stroke Nurse Navigator or Neuro Telemetry Unit Charge Nurse/ Rapid Response Team as designed coverage: a. Stroke Program Manager/Stroke Nurse Navigator or designated coverage (Neuro Telemetry Unit Charge Nurse/ Rapid Response Team) reports to the bedside within 15 minutes of notification. b. performs a National Institutes of Health Stroke Scale (NIHSS) ... 4. Critical Care Registered Nurse: a. performs a National Institutes of Health Stroke Scale (NIHSS) prior to thrombolytic (to dissolve blood clots) agent administration and documents in the electronic medical record."

Based on interview and record review, the facility failed to:

1. Ensure its nursing staff adhered to physician order and facility's policy and procedure regarding intravenous (IV, administered into a vein) titratable (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) medications when Nursing staff administered and titrated IV nicardipine (medication to treat high blood pressure) without proper titration (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) and blood pressure (BP, normal blood pressure is generally considered to be less than 120/80 mmHg [millimeters of mercury, unit of measure]) monitoring for two of 41 sampled patients (Patient 1 and Patient 4).

This deficient practice resulted in Patient 1's blood pressure (BP) drop, from 222/116 millimeters of mercury (mmHg, unit of measure) to 67/40 mmHg within 1 hour and 30 minutes (from 6 p.m. to 7:30 p.m.), compromising Patient 1's perfusion (process of blood carrying oxygen and nutrients to the body tissues and organs) to the brain. This deficient practice also had the potential to put Patient 4 at risk for hypotension (low blood pressure).

2. Discontinue the nicardipine (Cardine IV infusion, a medication to control blood pressure and prevent cerebral [brain] venous spasm) and obtain a new physician order to restart Nicardipine IV infusion for one of 41 sampled patients (Patient 27), when Nicardipine IV was restarted beyond the 23 hours of its last administration (the order should have been discontinued and deemed inactive), in accordance with the original physician order set and the facility's policy regarding titratable medications (slowly increasing the dose of a medicine by very small amounts over time [minutes, hours, days, weeks]).

This deficient practice resulted in inappropriate administration of nicardipine to Patient 27 (beyond the prescribed duration), placing Patient 27 at increased risk of harm such as severe hypotension (low blood pressure) thus compromising Patient 27's safety.

3. Discontinue propofol (a medication used for general anesthesia induction and maintenance, sedation during monitored anesthesia care, and sedation) and obtain a new physician order to restart propofol infusion for one of 41 sampled patients (Patient 26), when propofol was continued beyond the 23 hours of its last administration, in accordance with the original physician order set and the facility's policy regarding titratable medications (slowly increasing the dose of a medicine by very small amounts over time [minutes, hours, days, weeks).

This deficient practice resulted in inappropriate administration of propofol to Patient 26 (beyond the prescribed duration), placing Patient 26 at increased risk of harm such as excessive sedation (drowsiness or sleep), respiratory depression (a breathing disorder characterized by slow or shallow breathing that doesn't allow for proper gas exchange in the lungs) and/or death.

On 5/28/2025 at 5:08 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Medical Officer (CMO), the Senior Director for Risk Management (SDRM), the Patient Care Executive/Chief Nursing Officer (CNO), the Director of Quality (DOQ), the Regulatory Specialist (RS) and via telephone, the Director for Accreditation and Licensing (DAL).
The facility failed to ensure its nursing staff adhered to the facility's policy and procedure and physician order in administering nicardipine (medication to treat high blood pressure) intravenously (IV, administered into a vein) to Patient 1, resulting in Patient 1 suffering hypotension (low blood pressure) when Patient 1's blood pressure (BP, normal blood pressure is generally considered to be less than 120/80 mmHg [millimeters of mercury, unit of measure]) changed from 222/116 millimeters of mercury (mmHg, unit of measure) to 67/40 mmHg within 1 hour and 30 minutes (from 6 p.m. to 7:30 p.m.) on 2/6/2025, compromising Patient 1's perfusion (process of blood carrying oxygen and nutrients to the body tissues and organs) to the brain. Patient 1's pupils were found non-reactive (the pupils do not constrict [get smaller] or dilate [get larger] when exposed to light).

On 1/24/2025, Patient 1 was admitted to the facility's Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) due to subarachnoid hemorrhage (life-threatening type of stroke caused by bleeding into the space surrounding the brain). Patient 1 underwent aneurysm coiling (a procedure to treat brain aneurysm [a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst], where small coils inserted into the aneurysm to block blood flow and prevent it from rupturing [burst]) on 1/24/2025. There was a physician order on 1/30/2025 to give IV nicardipine to keep systolic blood pressure (first number of blood pressure when the heart contracts and pushes out blood) below 180 mmHg with initial (starting) rate of 5 milligram per hour (mg/hr, unit of measure), increment (an increase) change at 2.5 mg/hr, frequency (how often) of increment of change at 15 minutes, and maximum dose of 15 mg/hr.

Patient 1 had IV nicardipine for blood pressure control on 1/30/2025 but the medication was not given since 2/1/2025. On 2/6/2025, at 5: 20 p.m., Patient 1 suddenly became unresponsive (does not react or move). At 6 p.m., Patient 1's blood pressure was 222/116 mmHg. At 7 p.m., Patient 1 was found with IV nicardipine infusing (running) at maximum dose rate at 15 mg/hr. The IV nicardipine was started at an unknown time and unknown initial rate. There was no blood pressure taken during IV nicardipine infusion. At 7:33 p.m., Patient 1's BP was 67/40 mmHg. IV nicardipine was stopped and IV norepinephrine (medication used to raise blood pressure in patients with severe hypotension) was started per physician order. Patient 1's pupils were found blown (pupils were abnormally dilated, fixed and unresponsive to light, suggestive brain damage) and non-reactive.

On 5/30/2025 at 5:50 p.m., the IJ was removed in the presence of CMO, SDRM, CNO, DOQ, RS and via telephone, the DAL. The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed through observation, interview, and record review.
The IJ Removal Plan indicated that for immediate action taken by the facility included a comprehensive review of all patients currently on IV titratable (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) medications to verify adherence to orders and documentation requirements. The facility also implemented to have pharmacy staff to review the blood pressure parameter on IV titratable medication prior to dispensing (to supply) of medication, and two-Registered Nurse (RN) verification (checking) when initiating and/or resuming any IV titratable medications, 2 RNs would verify the order including name of medication, dosing, frequency, parameters, indication and last infusion time. Primary RN would scan the IV titration medication to validate the order and record administration time and initial infusion rate. RN to monitor and document minimum vital signs including blood pressure, heart rate and mean arterial blood pressure (MAP, a critical measurement of blood pressure that reflects the average arterial pressure throughout the cardiac [heart] cycle) prior to IV titratable medication administration, before and after each titration, and when resuming or restarting the infusion until the therapeutic goal was met.

Education began on 5/28/2025 with Intensive Care Unit (ICU) nursing staff and pharmacy staff that were on duty on 5/28/2025. This education was also repeated before the shift started for the day shift on 5/29/2025 and will continue to be repeated on all shifts at the beginning of each shift until all nursing and pharmacy staff have been re-educated. All ICU nursing staff would be checked off for competency (assessment of a clinician's skills, abilities and knowledge to ensure provision of safe and effective care to patients) for titratable medication validation.

The IJ removal plan also included monitoring and auditing plans to ensure that nursing staff were administering IV titratable medication properly per physician order, there was proper monitoring of vital signs when patients were receiving IV titratable medications and 2-RN verification would be used. Audits were also done and will continue regarding IV titratable medication administration and monitoring.

Findings:

1.a. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/24/2025, the "H&P" indicated, Patient 1 was admitted to the facility's Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) with diagnoses including but not limited to subarachnoid hemorrhage (life-threatening type of stroke [occurs when blood flow to the brain is disrupted, either by a blockage or a burst blood vessel] caused by bleeding into the space surrounding the brain), status post aneurysm coiling (a procedure to treat brain aneurysm [a bulge in the arteries of brain, potentially leading to a stroke if ruptured [burst]) on 1/24/2025 and uncontrolled hypertension (high blood pressure).

During a review of Patient 1's "Order Sheet (physician order sheet, orders written by physicians to direct care and treatment)," dated 1/30/2025, the physician order sheet indicated, to give nicardipine (medication to treat high blood pressure) intravenously (IV, administered into a vein) to keep systolic blood pressure (first number of blood pressure when the heart contracts and pushes out blood) less than 180 millimetres of mercury (mmHg, unit of measure) with initial (starting) rate of infusion (running) at 5 milligrams per hour (mg/hr, unit of measure), increment (an increase) of change at 2.5 mg/hr, frequency (how often) of increment of change every 15 minutes, maximum dose rate at 15 mg/hr. The physician order sheet also indicated, "discontinue order if rate remains at zero (0) for 23 hours."

During an interview on 5/27/2025 at 3:14 p.m. with the Intensive Care Unit (ICU) Registered Nurse (RN) 3, RN 3 stated the following: nurse should start IV nicardipine at 5mg/hr and titrate (gradually adjusting the dose of a drug over time to find the most effective and safest dose for a patient) per physician order. There should be a set of vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level) to coordinate with each titration.

During an interview on 5/28/2025 at 10:56 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: RN 1 found Patient 1 nonresponsive (does not react or move) on 2/6/2025 around 5:20 p.m., Patient 1's BP was 222/116 mmHg at 6 p.m. Patient 1 was sent to radiology (a department that utilizes various imaging techniques to diagnose and treat diseases) for STAT (a medical abbreviation for immediately or without delay) CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head scan. RN 2 received Patient 1 at change of shift at 7 p.m. and noted Patient 1 receiving IV nicardipine at 75 ml/hr (15mg/hr, maximum dose).

During a review of facility's medication dispensing (to supply) record titled, "All Transaction Activity Detail Report (dispensing record)," dated 2/6/2025, the dispensing record indicated, RN 1 retrieved one bag of IV nicardipine 40 mg per 200 milliliters (ml, unit of measure) for Patient 1 on 2/6/2025 at 6:22 p.m.

During a concurrent interview and record review on 5/28/2025 at 11:24 a.m. with the Stroke Coordinator (SC 1), Patient 1's "Medication Administration Record (MAR, record of medications given to patients)," dated from 1/31/2025 to 2/6/2025, was reviewed. The MAR indicated, Patient 1 received IV nicardipine infusion starting on 1/31/2025 with initial rate at 5 mg/hr and it was titrated to zero (0) on 2/1/2025 at 7:45 a.m. Nicardipine infusion rate was zero (0) from 2/2/2025 to 2/5/2025. The MAR also indicated, on 2/6/2025 at 7 p.m., nicardipine was given at 15mg/hr with a comment indicating, "received patient (Patient 1) at this rate."

During the same interview on 5/28/2025 at 11:24 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: IV nicardipine was started for BP control and it was titrated to zero when the BP was within desired range. Patient 1 did not receive any nicardipine from 2/2/2025 to 2/5/2025. The nicardipine order should have been discontinued on 2/2/2025 by 6:45 a.m. since the last administration (2/1/2025) was over 23 hours. A new order was required to restart IV nicardipine. It was unknown what time and what initial rate nicardipine was restarted on 2/6/2025 because it was not documented. The medication was not titrated correctly.

During a concurrent interview and record review on 5/28/2025 at 11:30 a.m. with the Stroke Coordinator (SC 1), Patient 1's "Vital Signs" flowsheet (vital signs flowsheet), dated 2/6/2025, was reviewed. The vital signs flowsheet indicated the following:

-At 5:40 p.m.: Heart Rate (HR) = 80 beats per minute (bpm), BP = 204/98 mmHg;
-At 6 p.m.: HR = 94 bpm, BP = 222/116 mmHg;
-At 7 p.m.: temperature = 97.9 degrees Fahrenheit (F, unit of measure 100.4 degrees Fahrenheit equivalent to 38.0 degrees Celsius) taken orally, no HR, and no BP documented; and
-at 7:33 p.m.: HR = 70 bpm, BP = 67/40 mmHg.

During the same interview on 5/25/2025 at 11:30 a.m. with the Stroke Coordinator (SC 1), SC 1 stated the following: there was no monitoring on Patient 1's blood pressure from 6 p.m. to 7:33 p.m. (1.5 hours) while Patient 1 was receiving IV nicardipine. Patient 1 became hypotensive (low blood pressure). Low blood pressure could affect perfusion (process of blood carrying oxygen and nutrients to the body tissues and organs) to the brain and contribute to no blood flow to brain.

During a concurrent interview and record review on 5/28/2025 at 11:40 a.m. with the Stroke Coordinator (SC 1), Patient 1's "Nursing Documentation - Flowsheet (nursing assessment)," dated 2/6/2025, was reviewed. The "Nursing Documentation - Flowsheet" indicated, at 3 p.m., Patient 1's both pupils were PERRLA (Pupils equal, round, and reactive to light and accommodation, standard eye exam to check the health of eyes and the nervous system) with regular, round, size 3 mm, reaction was brisk (quick and full constriction) and consensual light reflex present; at 7 p.m. Patient 1's both pupils were not PERRLA with regular, round, size 5 mm, nonreactive. SC 1 stated it was a drastic change in neurological assessment (evaluation the function of the nervous system which comprise with brain, spinal cord and peripheral nerves). Patient 1's both pupils were blown (pupils were abnormally dilated, fixed and unresponsive to light) indicating there was no brain function, the brain was not perfusing.

During a review of Patient 1's "Physician Communication (physician communication note, documentation between nurse and physician communication regarding patient's condition and test result)" note, dated 2/6/2025, the physician communication note indicated, at 7:28 p.m., RN 2 informed physician (MD 2) that Patient 1 was hypotensive, MD 2 ordered to stop nicardipine and start Levophed (norepinephrine, medication used to raise blood pressure in patients with severe hypotension).

During a review of Patient 1's "Neurosurgery Progress Note (neurosurgeon note, physician progress note completed by neurosurgeon)," dated 2/7/2025, the neurosurgeon note indicated, "(Patient 1) had sudden loss of conscious (unresponsive) yesterday. STAT CT showing large frontal (front part of the brain behind the forehead) hemorrhage (bleeding). Was started on Cardene (nicardipine, medication given intravenously [IV, directly into a vein) to lower blood pressure) for blood pressure management ... became bradycardic (low heart rate) and hypotensive (low blood pressure). Started pressor (medication to raise up the blood pressure) ... loss of brain stem reflexes (involuntary motor responses originating from the brainstem that control breathing, heart rate, and balance) were noted ... this morning remains unresponsive. No cough/ gag reflex (a natural protective mechanism that prevents objects from entering the throat and potentially causing choking). No pupillary (relating pupil of the eye) or oculocephalic reflexes (a neurological reflex where the eyes move in the opposite direction of a rapid head rotation). No responses to painful stimuli. And not breathing over the ventilator (an appliance for artificial respiration). It was likely the patient has progressed to brain death (irreversible cessation of all brain function)."

During an interview on 5/29/2025 at 1:58 p.m. with the Director of Pharmacy (DIR 1), DIR 1 stated each IV titration medication order would include how much to start, how often to titrate, how much to titrate to achieve the set goal. Nurses needed to follow the medication order when titrating medications.

During an interview on 5/30/2025 at 11:27 a.m. with the ICU Director (DIR 2), DIR 2 stated the following: nurses must follow physician order when administering any titratable medication. Nurses could not change the medication dose, route, frequency without physician order. Nurses could not titrate nicardipine more frequent than every fifteen minutes per physician order. Nurses should monitor patient's vital signs throughout titration to evaluate his/her response to the medication.

During an interview on 5/30/2025 at 4 p.m. with the Medication Safety Officer (MSO), MSO stated Patient 1's nicardipine incident was identified as a medication error because IV nicardipine was restarted despite it not being used for more than 23 hours (last administration was 2/1/2025) and there was no new order to give IV nicardipine on 2/6/2025.

During a review of the facility's policy and procedure (P&P) titled, "Titratable Medication Infusion Administration," dated 9/2021, the P&P indicated, "the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Titration medication orders ... the nurse must stay within the defined parameters of the medication orders ... Titratable medication documentation. 1. Titratable medication must be documented at the time of administration within MAR. 2. The goal of the titratable medication ... must be documented prior to initiating the titratable infusion and during each rate change. 3. Documentation will accurately reflect order changes and patient assessments ... Discontinuing a titratable medication. 1. A titratable infusion order will include the order detail that the infusion should be discontinued from the MAR when the patient has not received the medication for 23 hours or more."

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 12/2024, the P&P indicated, "Medication Administration should be performed by licensed medical staff according to manufacturer's prescribing information and in accordance with FDA (Food and Drug Administration, a government agency) regulations. Proper documentation, verifying patient specific information, medication security and compliance with specific drug policies should always be taken during medication administration ... Procedure ... Utilize the seven rights for administering medication: a. Right Patient b. Right Dose c. Right Time d. Right Route e. Right Drug f. Right to Refuse ... g. Right to be Educated ... Check all medications and IV solutions against eMAR (electronic medication administration record)/MAR ... access eMAR/MAR and/or physician order when administering medications at patient's bedside ... Documentation: 1. Medication administration should be documented immediately after administration, but no later than 1 hour after administration... Documentation should occur in the eMAR/MAR."

During a review of medication package insert (provide medication information and its use) for nicardipine, dated 10/2014, the medication package insert indicated, "Dosage and Administration ... Recommend Dosing ... Dosage for initiation of therapy in a patient not receiving oral nicardipine. Initiate therapy at 25 ml/hr (5mg/hr). If desire blood pressure reduction is not achieved at this dose, the infusion rate may be increased by 12.5ml/hr (2.5mg/hr) every five (5) minutes (for rapid titration) to 15 minutes (for gradual titration) up to a maximum of 75 ml/hr (15mg/hr), until desired blood pressure reduction is achieved. Following achievement of the blood pressure goal utilizing rapid titration, decrease the infusion rate to 15ml/hr (3mg/hr)."

During a review of the facility's policy and procedure (P&P) titled, "Standards of Nursing Practice Critical Care Department (Intensive Care Unit)," dated 2/25/2025, the P&P indicated, "Patients on intravenous (IV) titratable medications: vital signs (except temperature) shall be assessed and documented at a minimum of approximately every 1 hour (or based on patient's clinical condition) ...When a RN actively titrating continuous intravenous (IV) infusion medications affecting vital signs ... then the frequency of vital signs should further align with the frequency of titrations (unless situation meets criteria for block charting). Patient monitoring and documentation should occur in a way that clearly justifies the need for titration/intervention and includes appropriate post-intervention follow-up by RN indicating the patient's response to medication titration."

During a review of the facility's policy and procedure (P&P) titled, "Medication Errors Reporting," 9/2022, the P&P indicated, "to establish procedures regarding medication errors and encourage all hospital staff to report all medication error reporting as a tool to enhance patient safety and prevent future errors ... Definitions: A. Medication Error - any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer ... Type of medication errors ... d. Administration error - types of administration errors may include: wrong patient, dose, time, medication, route, rate ... and unauthorized dose given."

1.b. During a review of Patient 4's "History and Physical," dated 2/18/2025, the H&P indicated, Patient 4 was admitted to the facility's Intensive Care Unit (ICU) for acute cerebrovascular accident (CVA, stroke; damage to the brain from interruption of its blood supply), status post thrombectomy (a procedure of removing blood clots from blood vessels) and hypertension (high blood pressure).During a concurrent interview and record review on 5/29/2025 at 10:43 a.m. with ICU RN 10, Patient 4's "Order Sheet (physician order sheet)," dated 2/18/2025, was reviewed. The physician order sheet indicated, to give nicardipine intravenously (IV) to keep systolic blood pressure (SBP) between 120 and 170 mmHg with initial rate of infusion at 5 mg/hr, increment of change at 2.5 mg/hr, frequency of increment of change every 15 minutes, maximum dose at 15 mg/hr. The physician order sheet also indicated, "discontinue order if rate remains at zero (0) for 23 hours." RN 10 stated the orders meant RN could only adjust the nicardipine rate at 2.5 mg/hr every 15 minutes each time.

During a concurrent interview and record review on 5/29/2025 at 10:44 a.m. with ICU RN 10, Patient 4's "Rapid Titration" flowsheet (rapid titration flowsheet, documentation recording IV titration mediation block charting [documentation method that can be used when rapid titration medication us necessary in specific urgent/emergent situations]), dated 2/19/2025, was reviewed. The rapid titration flowsheet indicated, "rapid titration medication: nicardipine; titration start time: 2/19/2025 at 10:30 a.m.; titration end time: 2/19/2025 at 10:45 a.m.; maximum dose achieved: 15 (mg/hr)." RN 10 stated RN 9 initiated block charting (a documentation method used in urgent or emergent situations involving rapid titration of medications, typically in discrete time intervals (e.g., 4 hours). It focuses on documenting the starting and ending doses/rates of medications, the maximum dose administered, and the patient's assessment at the beginning and end of the block) and titrated IV nicardipine and to reach to maximum dose at 15mg/hr within 15 minutes.During a concurrent interview and record review on 5/29/2025 at 11 a.m. with RN 10, Patient 4's Medication Administration Record (MAR), dated from 2/18/2025 to 2/19/2025, was reviewed. The MAR indicated the following: the IV nicardipine infusion rate was started on 2/18/2025 at 5 mg/hr. It was titrated to zero (0) mg/hr on 2/19/2025 at 1:50 a.m., the rate was changed to 2.5 mg/hr at 7 a.m., next rate changed to 15mg/hr at 10:44 a.m. The MAR indicated there was no rate change between 7 a.m. and 10:44 a.m.

During an interview on 5/29/2025 at 11:11 a.m. with RN 10, RN 10 stated the following: RN 9 titrated IV nicardipine from 2.5 mg/hr to 15 mg/hr within 15 minutes. RN 9 titrated IV nicardipine outside what was ordered. RN 9 did not follow the titration frequency in the medication order. It could cause Patient 4's blood pressure dropping too fast and become hypotensive (low blood pressure).

During a concurrent interview and record review on 5/29/2025 at 11:20 a.m. with RN 10, Patient 4's "Vital Signs" flowsheet (vital signs flowsheet), dated 2/19/2025, was reviewed. The vital signs flowsheet indicated the following:

-7 a.m. heart rate (HR) = 79 beats per minutes (bpm) and blood pressure (BP) = 171/85 mmHg;
-8 a.m. HR = 77 bpm and BP = 140/80 mmHg;
-9 a.m. HR = 76 bpm and BP 143/76 mmHg;
-10 a.m. HR = 83 bpm and BP = 167/85 mmHg;
-10:29 a.m. HR = 82 bpm and BP = 165/80 mmHg; and
-10:44 a.m. HR = 100 bpm and BP = 206/91 mmHg.

During the same interview on 5/29/2025 at 11:20 a.m. with RN 10, RN 10 stated the following: Patient 4's BP at 10:29 a.m. was within ordered parameters (to keep SBP between 120 and 170 mmHg), there was no need to titrate the IV nicardipine. There was missing one set of vital signs to evaluate Patient 4's response during the IV nicardipine titration (between 10:29 a.m. and 10:44 a.m.). Nurse should have monitored vital signs during block charting to make sure goal was achieved, to evaluate the effectiveness of the medication and to make sure there was no adverse effect.

During an interview on 5/30/2025 at 11:27 a.m. with the ICU Director (DIR 2), DIR 2 stated the following: the facility did not have a rapid titration policy. Nurses must follow physician order when administering any titratable medication. Nurses could not change the medication dose, route, frequency without physician order. Nurses could not titrate nicardipine more frequent than every fifteen minutes per physician order. Nurses should monitor patient's vital signs throughout titration to evaluate his/her response to the medication.

During an interview on 5/30/2025 at 11:39 a.m. with the ICU Director (DIR 2), DIR 2 stated Patient 4's blood pressure on 2/19/2025 at 10:29 a.m. did not meet criteria for emergent or urgent situation. DIR 2 stated there was no indication for block charting.

During an interview on 5/30/2025 at 3:51 p.m. with the Medication Safety Officer (MSO), MSO stated Patient 4's rapid titration of IV nicardipine on 2/6/2025 at 10:30 a.m. should be reported as medication error because the medication was not given how the physician had ordered. MSO stated there was no report on this incident.

During a review of the facility's policy and procedure (P&P) titled, "Titratable Medication Infusion Administration," dated 9/2021, the P&P indicated, "the purpose of this policy is to define and establish requirements for safe and accurate administration and documentation of titratable infusion medication orders... Titration medication orders ... the nurse must stay within the defined parameters of the medication orders ... Titratable medication documentation. 1. Titratable medication must be documented at the time of administration within MAR. 2. The goal of the titratable medication ... must be documented prior to initiating the titratable infusion and during each rate change. 3. Documentation will accurately reflect order changes and patient assessments. 4. Documenting each individual rate change during an urgent/emergent situation can potentially create undue burden. In these situations, block charting can be instituted. a. Block charting is a method of documenting rapid titrations. b. Documentation of block must be completed in the EHR (electronic health record). c. Block charting includes the initial rate, ending rate, and max rate of medication infusions administered without documenting the incremental titration adjustments within a specific time period to accomplish the desired goal ... f. the minimum elements that must be documented in each block charting episode are: i. Time of initiation and completion of the charting block. ii. Name(s) of medications administered during the block. iii. Initial rate and ending rate of medication infusions administered during the charting block. iv. Maximum rate (dose) of medications administered during the charting block. v. physiological parameters and goal evaluated during the charting block."

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 12/2024, the P&P indicated, "Medication Administration should be performed by licensed medical staff according to manufacturer's prescribing information and in accordance with FDA (Food and Drug Administration, a government agency) regulations. Proper documentation, verifying patient specific information, medication security and compliance with specific drug policies should always be taken during medication administration ... Procedure ... Utilize the seven rights for administering medication: a. Right Patient b. Right Dose c. Right Time d. Right Route e. Right Drug f. Right to Refuse ... g. Right to be Educated ... Check all medications and IV solutions against eMAR (electronic medication administration record)/MAR ... access eMAR/MAR and/or physician order when administering medications at patient's bedside ... Documentation: 1. Medication administration should be documented immediately after administration, but no later than 1 hour after administration... Documentation should occur in the eMAR/MAR."During a review of medication package insert (provide medication information and its use) for nicardipine, dated 10/2014, the medication package insert indicated, "Dosage and Administration ... Recommend Dosing ... Dosage for initiation of therapy in a patient not receiving oral nicardipine. Initiate therapy at 25 ml/hr (5mg/hr). If desire blood pressure reduction is not achieved at this dose, the infusion rate may be increased by 12.5ml/hr (2.5mg/hr) every 5 minutes (for rapid titration) to 15 minutes (for gradual titration) up to a maximum of 75 ml/hr (15mg/hr), until desired blood pressure reduction is achieved. Following achievement of the blood pressure goal utilizing rapid titration, decrease the infusion rate to 15ml/hr (3mg/hr)."

During a review of the facility's policy and procedure (P&P) titled, "Standards of Nursing Practice Critical Care Department (Intensive Care Unit)," dated 2/25/2025, the P&P indicated, "Patients on intravenous (IV) titratable medications: vital signs (except temperature) shall be assessed and documented at a minimum of approximately every 1 hour (or based on patient's clinical condition) ...When a RN actively titrating continuous intravenous (IV) infusion medications affecting vital signs ... then the frequency of vital signs should further align with the frequency of titrations (unless situation meets criteria for block charting). Patient monitoring and documentation should occur in a way that clearly justifies the need for titration/intervention and includes appropriate post-intervention follow-up by RN indicating the patient's response to medication titration."

During a review of the facility's policy and procedure (P&P) titled, "Medication Errors Reporting," 9/2022, the P&P

Based on interview and record review, the facility failed to ensure that medical records for 20 of 41 sampled patients (Patients 2, 3, 8, 9, 10, 11, 12, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39) were accurately written or documented, in accordance with the facility's policies regarding medical record content and completeness, as evidenced by:

1. The rounds (a systematic process where a healthcare team member checks on a patient regularly) conducted, every 15 minutes, in the East side of the Psychiatric (relating to mental illness) Acute Care unit, were inaccurately documented in the medical record for 19 of 19 patients (Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39).

This deficient practice led to the inaccurate documentation on 5/7/2025 at 4:15 a.m., that 19 patients had been visualized by a staff, when in fact, the round was not conducted at that time. This deficient practice also placed 19 patients' safety at risk such as self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence.

2. For Patient 27, the electronic medical record (eMR, digital version of paper chart) titled, "Medication Administration Record (MAR)," did not accurately reflect the documentation of the peripheral intravenous line (PIV, a short, flexible plastic tube [catheter] inserted into a vein for the purpose of administering fluids, medications, or blood products) used to administer nicardipine (a medication used to treat hypertension [high blood pressure, a condition where the force of blood pushing against the walls of the arteries is consistently too high]).

This deficient practice had the potential for Patient 27's PIV site to be inadequately monitored for complications such as infiltration (the inadvertent delivery of fluid or medication into surrounding tissue that has the potential to harm the patient), phlebitis (inflammation of the vein), or extravasation (the leakage of fluid or substances from a blood vessel or other enclosed space into the surrounding tissues), leading to tissue damage, tissue ischemia (blood flow to a tissue or organ is restricted or reduced) , or necrosis (death of the tissue), and if undetected, may result in delayed treatment and/or negative health outcomes for Patient 27.

Findings:

1. During a review on 5/28/2025 at 10:25 a.m., a Video footage, dated 5/7/2025 of the East side of the Psychiatric Acute Care Unit, was reviewed. The following was reviewed with Nurse Managers (NM) 1 and NM 2. The video footage indicated that on 5/7/2025 at 4:15 a.m., Licensed Vocational Nurse (LVN) 2 was not seen in the hallway conducting rounds on Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39. NM 1 stated that rounds should be conducted every 15 minutes by going into patient rooms and checking for a safe environment, patients' condition, behavior, and whether the patient was breathing or sleeping. NM 1 stated that the round on 5/7/2025 at 4:15 a.m., was missed. NM 1 stated that LVN 2 documented that she (LVN 2) had conducted rounding at 4:15 a.m., and that the documentation was falsified (false or incorrect).

During a review of a document titled, "Patient Observation Checklist - Psych Acute Care - East," dated 5/7/2025, the document indicated Patients 2, 3, 8, 9, 10, 11, 12, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39 were on the unit. At 4:15 a.m., Patients 12 and 30 were in their room, awake. At 4:15 a.m., Patients 2, 3, 8, 9, 10, 11, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, and 39 were in their room, asleep.

During a review of Patient 2's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/19/2025, the H&P indicated the following: Patient 2 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for Grave Disability (a person who is unable to care for their basic needs due to a mental health disorder).

During a review of Patient 3's History and Physical (H&P), dated 5/01/2025, the H&P indicated Patient 3 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for suicidal ideations (thoughts of harming self).

During a review of Patient 8's History and Physical (H&P), dated 4/19/2025, the H&P indicated Patient 8 was admitted to the facility on a 5150 hold for grave disability.

During a review of Patient 9's Behavioral History and Physical (H&P), dated 4/29/2025, the H&P indicated Patient 9 was admitted to the facility on a 5150 hold for danger to self and danger to others.

During a review of Patient 10's Behavioral History and Physical (H&P), dated 5/5/2025, the H&P indicated Patient 10 was admitted to the facility on a 5150 hold for danger to self. Patient 10 had a history of major depression (serious mental disorder characterized by persistent feelings of sadness, loss of interest in activities, and a range of other symptoms that interfere with daily life).

During a review of Patient 11's Behavioral History and Physical (H&P), dated 4/4/2025, the H&P indicated Patient 11 was admitted to the facility on a 5150 hold for grave disability.

During a review of Patient 12's Behavioral History and Physical (H&P), dated 5/2/2025, the H&P indicated Patient 12 was admitted to the facility on a 5150 hold for grave disability.

During a review of Patient 28's Behavioral History and Physical (H&P), dated 4/17/2025, the H&P indicated Patient 28 was admitted to the facility on a 5150 hold for grave disability.

During a review of Patient 29 's Behavioral History and Physical (H&P), dated 5/3/2025, the H&P indicated Patient 29 was admitted to the facility on a 5150 hold for grave disability.

During a review of Patient 30 's Behavioral History and Physical (H&P), dated 4/30/2025, the H&P indicated Patient 30 was admitted to the facility on a 5150 hold for grave disability and danger to self.

During a review of Patient 31 's Behavioral History and Physical (H&P), dated 5/6/2025, the H&P indicated Patient 31 was admitted to the facility on a 5150 hold for danger to self.

During a review of Patient 32's Behavioral History and Physical (H&P), dated 5/04/2025, the H&P indicated Patient 32 was admitted to the facility because of delusions (persistent, false beliefs held with a strong conviction despite evidence to the contrary) and uncontrolled behavior.

During a review of Patient 33's History and Physical (H&P), dated 5/03/2025, the H&P indicated Patient 33 was admitted to the facility on a 5150 hold for being gravely disabled. Patient 33's diagnosis included psychosis (disconnection from reality) and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly).

During a review of Patient 34's History and Physical (H&P), dated 3/22/2025, the H&P indicated Patient 34 was admitted to the facility on a 5150 hold for grave disability. Patient 34's diagnosis included schizophrenia.

During a review of Patient 35's Behavioral History and Physical (H&P), dated 5/05/2025, the H&P indicated Patient 35 was admitted to the facility on a 5150 hold for being a danger to self (thoughts of harming self).

During a review of Patient 36's History and Physical (H&P), dated 5/04/2025, the H&P indicated Patient 36 was admitted to the facility for psychosis and suicidal ideations.

During a review of Patient 37's Behavioral History and Physical (H&P), dated 4/29/2025, the H&P indicated Patient 37 was admitted to the facility on a 5150 hold for being a danger to self. Patient 37's diagnosis included schizophrenia.

During a review of Patient 38's Behavioral History and Physical (H&P), dated 1/25/2025, the H&P indicated Patient 38 was admitted to the facility for aggressive behavior and suicidal ideations. Patient 38 was on a 5150 hold for danger to self.

During a review of Patient 39's History and Physical (H&P), dated 3/15/2025, the H&P indicated Patient 39 was admitted to the facility for being agitated and aggressive and on a 5150 hold for being a danger to others and grave disability.

During a review of the facility's policy and procedure (P&P) titled, "Medical Record Content and Completeness," dated 12/06/2024, the P&P indicated the following: Policy Summary/Intent: ...To outline the hospital policy to provide a medical record for all patients that is timely, meaningful, an authentic (real, true) and legible description of the patient's clinical condition and hospital course ...To define complete and properly documented patient medical record that supports patient care, reimbursement, justifies treatment as required ...by regulatory agencies.

2. During a review of Patient 27's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/24/2025, the H&P indicated that Patient 27 was admitted to the facility with a diagnosis of subarachnoid hemorrhage (SAH, a type of stroke [a medical emergency that occurs when the brain's blood supply is disrupted, causing brain damage] caused by bleeding into the subarachnoid space, which is the area between the brain and the thin tissues [meninges] that cover it) and ruptured brain aneurysm (a medical condition where a weakened, bulging area in a blood vessel wall in the brain bursts, causing bleeding within the brain).

During a review of Patient 27's medical record (MR) titled, "Order Sheet," dated 5/24/2025, the MR indicated that Patient 27 had an order for nicardipine drip (the drug [intended to lower blood pressure, BP] is given as a continuous infusion at a starting dose of 5 milligrams per hour [mg/hr, measuring unit] followed by increments of 2.5 mg/hr every 5 minutes until either reaching a maximal dose of 15 mg/hr or achieving the desired reduction in BP) placed on 5/24/2025.

During a concurrent interview and record review on 5/29/2025 at 3:13 p.m. with Registered Nurse (RN) 6, Patient 27's "Order Sheet," was reviewed. The Order Sheet indicated that on 5/24/2025 [at 8:31 a.m.], an order for nicardipine (Cardene I.V.) continuous drip was placed with the following order comments: "Minimize peripheral venous infiltration (the inadvertent delivery of fluid or medication into surrounding tissue that has the potential to harm the patient) by changing infusion site every 12 hours." RN 6 reviewed Nicardipine IV order details and stated that the peripheral I.V. site documentation should demonstrate the alternation in PIV site during Nicardipine IV infusion.

During a review of Patient 27's Medication Administration Record (MAR), particularly administration of the continuous nicardipine drip (infusion) and the associated peripheral intravenous (PIV) site record, dated 5/25/2025 through 5/29/2025, the record indicated that that on all occasions, Patient 27's PIV was documented to be in the right antecubital (AC, the area of the inner elbow). This information was verified with the registered nurse (RN 6) during record review on 5/29/2025 at 2:56 p.m.

During a review of Patient 27's nursing flowsheet titled, "Peripheral Intravenous (PIV) Lines," dated 5/27/2025, the flowsheet indicated that Right antecubital (Rt AC) line was discontinued and removed on 5/27/2025 at 10:43 p.m. and Left antecubital (Lt AC) line was documented to be inserted on 5/27/2025 at 3:15 a.m.

During a concurrent interview and record review on 5/29/2025 at 3:13 p.m. with Registered Nurse (RN 6), Patient 27's Medication Administration Record (MAR), particularly administration of the continuous nicardipine drip (infusion) and the associated peripheral intravenous (PIV) site record, dated 5/25/2025 through 5/29/2025, was reviewed. RN 6 confirmed that nursing staff continued documentation of right antecubital" (Right AC) as the IV site associated with nicardipine infusion through the reviewed date of 5/29/2025 at 3:13 p.m., even though the right antecubital line was recorded to have been discontinued and removed on 5/27/2025 at 3:15 a.m.

During an interview on 5/29/2025 at 3:11 p.m. with registered nurse (RN 6), RN 6 stated the following, "We [nurses] document the peripheral IV site associated with the administration of a medication to enable tracing of any side effects related to the medication infusion." RN 6 also said that accurate documentation allowed [nurses] to identify and assess the site for complications such as phlebitis (inflammation of the vein), pain, swelling, or vesicants (substances that can cause tissue damage or blistering if extravasation occurs) which was essential for early detection and timely intervention to prevent tissue injury and ensure patient safety.

During a review of the nicardipine safety data sheet (SDS, a document that provides information about the potential hazards of a chemical or substance, along with guidance on how to handle, store, and dispose of it safely), dated 10/2014, the SDS indicated the following: "Administer Cardene I.V. (Nicardipine) by a central line or through a large peripheral vein. Change the infusion site every 12 hours if administered through peripheral vein to reduce the possibility of venous thrombosis, phlebitis, local irritation, swelling, extravasation, and the occurrence of vascular impairment. To minimize the risk of peripheral venous infiltration, change the site of the drug infusion every 12 hours."

Based on interview and record review, the facility failed to ensure that for one of 41 sampled patients (Patient 5), a death note (a documented record in the medical record to indicate the patient's death, including the cause and circumstances), was completed and filed in Patient 5's electronic medical record (eMR, digital version of paper charting) to formally document and record the death of a patient (Patient 5), in accordance with the facility's policy regarding medical record content and completeness.

This deficient practice violated Patient 5's rights (the legal protections and ethical considerations that ensure individuals receive respectful, equitable, and informed medical care) with regards to the completeness and integrity of the medical record, potentially damaging a patient's and their family's trust in the healthcare system and their providers.

Findings:

During a review of Patient History and Physical (H&P, a comprehensive formal assessment used by healthcare providers to evaluate a patient's health and medical condition, typically during an initial visit or before a procedure), dated 2/26/2025, the H&P indicated that Patient 5 was admitted with a diagnosis of sepsis (a life-threatening medical emergency that occurs when the body's extreme response to an infection damages its own tissues and organs).

During a review of Patient 5's "Discharge Summary," dated 1/15/2025, the Discharge Summary indicated, that Patient 5 died after developing a multisystem organ failure (two or more of the organ systems are failing to support the body's needs) and being on maximum dose of 4 pressors (medications or substances that raise blood pressure).

During a concurrent interview and record review on 5/28/2025, at 11:15 a.m. with registered nurse (RN) 13, Patient 5's electronic health record (EHR), dated 12/26/2023 through 1/1/2024, was reviewed, to locate the death note (the documentation of a patient's death, including the time and date of death, the reason for death, and other relevant details). RN 13 said that Patient 5's EHR did not contain a completed and filed death note for Patient 5. RN 13 reviewed the "Discharge Summary," report, dated 1/1/2024, and stated that the record did not indicate how Patient 5 died and when [date and time].

During an interview on 5/30/2025 at 2:47 p.m. with the Chief Medical Officer (CMO), the CMO reviewed Patient 5's "Discharge Summary/Death Summary, dated 1/1/2024, and said that this document was solely a discharge summary, not a Death Note. The CMO further said that a death note should include the official statement indicating that the patient had died, including the date and time of death, the cause of death, and the course of treatment prior to the patient's passing, such as whether a rapid response (RRT, activated when a patient's condition is deteriorating but not yet in cardiac or respiratory arrest) was called or a code blue (a medical emergency where a patient has stopped breathing or has no heartbeat, requiring immediate resuscitation efforts) was activated.

During the same interview on 5/30/2025 at 2:47 p.m., with the Chief Medical Officer (CMO), the CMO stated that both, patient's discharge summary and death note, were expected to be completed and filed within five to seven days.

During a review of the facility's policy and procedure (P&P) titled, "Medical Record Content and Completeness," dated 12/6/2024, the P&P indicated that all records are to be available in the Electronic Health Records (EHR) 48 hours of discharge. All clinical entries in the patient medical record shall be considered complete when the required contents are filed in the EHR ... to ensure that the medical record contains patient specific data justifying admission and treatment, patient's clinical condition and hospital course ... and to ensure that medical documentation follows regulatory requirements...

Based on interview and record review, the facility failed to ensure that for one of 41 sampled patients (Patient 24), a comprehensive medical history and physical examination (H&P, a formal assessment of a patient that includes gathering their medical history and performing a physical examination) was completed, documented, and filed within 24 hours of Patient 24's admission and prior to surgery, in accordance with the facility's policy regarding chart completeness.

This deficient practice had the potential to compromise Patient 24's safety by delaying the identification of underlying health issues, contraindication, or risks that could impact surgical outcomes. In addition, this deficient practice can lead to inappropriate delayed medical interventions for Patient 24, increased risk of perioperative complications, and adverse events, or harm to the patient (Patient 24) due insufficient baseline assessment and incomplete documentation.

Findings:

During a review of Patient 24's "Emergency Department (ED) Physician Note," dated 5/27/2025, the note indicated that on 5/27/2024, Patient 24 was seen and evaluated by the Emergency Department (ED, a hospital facility that provides immediate medical care to patients who need urgent attention) physician due to active bleeding and large volume hemoptysis (coughing up blood or bloody mucus from the respiratory tract (lungs and throat). The ED physician note also indicated that Patient 24 underwent tonsillectomy (a surgical procedure where the tonsils are removed) two weeks ago ... The note further indicated that Patient 24 was going to be taken to the operating room for surgical management of bleeding.

During a concurrent interview and record review on 5/29/2025 AT 11:09 a.m. with registered nurse (RN 6), Patient 24's electronic medical record (EMR, digital version of paper chart), was reviewed. RN 6 stated that History and Physical (H&P, a comprehensive formal assessment used by healthcare providers to evaluate a patient's health and medical condition, typically during an initial visit or before a procedure) was not filed in Patient 24's electronic medical record (eMR).

During a review of Patient 24's "Critical Care Consultation Note," dated 5/27/2025, the note indicated that Patient 24 underwent surgical control of ongoing bleeding and was admitted to the intensive care unit (ICU, a specialized hospital ward designed to provide advanced critical care to patients who are critically ill or injured) on 5/27/2025 for monitoring.

During an interview on 5/20/2025 at 2:44 p.m. with the Chief Medical Officer (CMO), the CMO stated the following regarding the facility's requirement for admitting physicians to complete a medical history and physical examination prior to admitting patient and/or performing a procedure/surgery: "The H&P must be completed within 24 hours of admission ... As patients pass through many departments, it is essential that all staff involved are informed of the patient's history, contraindication, medications, and allergies to ensure safe and coordinated care."

During a review of the facility's policy and procedure (P&P) titled, "Chart Completeness upon Discharge," dated 11/2022, the P&P indicated that History and Physical (H&P) examination shall be recorded in the medical record within 24 hours after admission or prior to surgery/procedure and the following elements are required to complete H&P:
I. Identification Data
II. Chief Complaint
III. History of Present Illness
IV. Past Medical History
V. Social and Family History
VI. Review of Systems
VII. Allergies
VIII. Medications
IX. Physical Examination, to include findings in those organ systems relevant to the presenting illness and to co-existing diagnosis

Based on interview and record review, the facility failed to ensure that for one of 41 sampled patients (Patient 23), a completed verified informed consent (a voluntary formal confirmation- agreement signed by the patient or their authorized representative that confirms they understand the nature, risks, benefits, and alternatives of a medical procedure before it is performed) for anesthesia (blocking pain signals to the brain, preventing a person from feeling pain during a procedure), was filled out indicating the type of anesthesia to be used during the procedure (laminectomy, a surgical procedure where a surgeon removes a portion of the lamina, which is the back part of the vertebra, to relieve pressure on the spinal cord or nerve roots), initials, date, time and witness signature in the area designated for anesthesia on the consent form, in accordance with the facility's policy regarding consents.


This deficient practice had the potential to negatively affect Patient 23's rights to decision-making (refers to the process in which patients are actively engaged in making informed choices about their healthcare options), undermining Patient 23's autonomy (person's right to make their own decisions) and compromise the legal validity (refers to legitimacy and enforceability of a document) of the consent due to lack of completeness of the medical record (verified informed consent form).

Findings:

During a review of Patient 23's History and Physical (H&P, a comprehensive formal assessment used by healthcare providers to evaluate a patient's health and medical condition, typically during an initial visit or before a procedure), dated 12/22/2023, the H&P indicated that Patient 23 was admitted for a planned laminectomy (a surgical procedure where a surgeon removes a portion of the lamina, which is the back part of the vertebra, to relieve pressure on the spinal cord or nerve roots) indicated for chronic ( persisting for a long time and constant) back pain.

During a review of Patient 23's History and Physical (H&P), dated 12/22/2023, the H&P also indicated that informed consent discussion took place between the physician, the patient (Patient 23) and Patient 23's Durable Power of Attorney (DPOA, a legal document that grants someone (the agent) the authority to make decisions on patient's behalf, even if patient becomes incapacitated or unable to make decisions) and the procedure, risks/benefits/alternatives, rationale for procedure, and anticipated post-operative course were discussed with the patient (Patient 23) and the DPOA, and both elected to proceed with the procedure (laminectomy).

During a review of Patient 23's informed consent for laminectomy, dated 12/25/2023, the consent indicated that the type of anesthesia (to be used during the procedure for laminectomy, [a surgical procedure where a surgeon removes a portion of the lamina, which is the back part of the vertebra, to relieve pressure on the spinal cord or nerve roots]), Patient 23's initials, date, time and witness signature in the area designated for anesthesia on the consent form, were not completed. This finding was verified during Patient 23's electronic health record (EHR) review on 5/28/2025 at 11:45 a.m. with registered nurse (RN) 13.

During a concurrent interview and record review on 5/28/2025 at 11:56 a.m. with the Director of Perioperative Services (DOP), Patient 23's informed consent for "Laminectomy," dated 12/25/2023, was reviewed. The DOP reviewed the consent and stated that the area dedicated to anesthesia was not marked as completed and was left blank. The DOP also said the informed consent was signed, and perhaps the nurse (who witnessed and signed obtaining the informed consent with Patient 23) or the patient (Patient 23) missed completing the anesthesia part of the consent.

During the same interview on 5/28/2025 at 11:56 a.m. with the Director of Perioperative Services (DOP), the DOP stated that anesthesia did not require a separate informed consent form and a designated area specifically outlining anesthesia, (which needed to be marked, initialed [by the patient] dated, timed, and witnessed with a signature), was found being missed by the nurses in the past when signing the consent with patients. The DOP also said that the facility recently changed the consent forms, so that the anesthesia section was no longer required to be separately marked and signed. The DOP said that the old, informed consent forms were still circulating within the facility.

During a review of the facility's policy and procedure (P&P) titled, "Consent and Informed Consent," dated 12/2024, the P&P indicated that consent for surgery or special procedure form should include ... the name of the patient, and when appropriate the patient's legal representative ... signature of witness, date and time ...

Based on interview and record review, the facility failed to ensure that for one of 41 sampled patients (Patient 26), nursing staff initiated, maintained, and documented a current nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for status epilepticus (a seizure [a sudden, temporary disturbance of the brain's normal electrical activity, often manifesting as changes in muscle tone, behavior, or awareness] lasting longer than five minutes or recurrent seizures without regaining full consciousness between them) that reflected the patient's (Patient 26's) goals and the nursing care to be provided to meet Patient 26's needs, in accordance with the facility's policy regarding care plans.

This deficient practice had the potential for Patient 26's care needs not to be met leading to adverse health outcomes for Patient 26, such as increased risk for injury during seizures, delayed recognition and response to seizure activity, lack of safety precautions to minimize the risk of harm during seizures. In addition, the lack of documented implementation of a seizure care plan had the potential to compromise communication among healthcare providers leading to disruptions in the continuity of care and Patient 26's safety.

Findings:

During a review of Patient 26's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/19/2025, the H&P indicated that Patient 26 was admitted to the facility with a diagnosis of status epilepticus (a continuous seizure [a sudden, temporary disturbance of the brain's normal electrical activity, often manifesting as changes in muscle tone, behavior, or awareness] lasting five minutes or more, or recurrent seizures without recovery in between) and had to be intubated (a tube has been inserted into the patient's windpipe (trachea) through their mouth or nose to help them breathe).

During a concurrent interview and record review on 5/29/2025 at 1:30 p.m. with registered nurse (RN) 6, Patient 26's electronic health record (EHR, electronic version of paper chart) titled, "Care Plans," dated 5/18/2025 through 5/29/2025, were reviewed. Patient 23's Care Plans (documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers), had no documented care plan for "Seizures." RN 6 verified the lack of developed and documented care plan for seizures for Patient 26 throughout their (Patient 26) admission stay at the facility [5/19/2025 through 5/29/2025]. RN 6 also verified that Patient 26's admission diagnosis was due to a seizure and stated that seizure precautions must be implemented for a patient admitted with seizures.

During the same interview and record review on 5/29/2025, at 1:30 p.m. with registered nurse (RN) 6, RN 6 reviewed Patient 26's electronic health record (EHR) in an attempt to locate documentation of seizure precautions anywhere in the patient's (Patient 26) health record. RN 6 verified that seizure precautions (safety measures taken before and during a seizure to prevent injury and ensure a person's well-being) were not recorded anywhere in Patient 26's health record (during admission from 5/19/2025 through 5/29/2025]. RN 6 then reviewed the available care plan for seizure precautions and stated that safety precautions can be documented in the intervention section of care plan once it's initiated.

During an interview on 5/30/2025 at 4:12 p.m. with registered nurse (RN) 6, RN 6 stated that a care plan was developed based on the patient's identified needs and problems, and it should include the establishment of specific goals to guide the development of appropriate interventions aimed at meeting the patient's individual needs and achieving the desired outcomes.

During a review of the facility's policy and procedure (P&P) titled, "Standards of Nursing Practice Critical Care Department (Intensive Care Unit)," dated 2/2025, the P&P indicated that nursing diagnoses and care issues are derived from the assessment data with the patient...and are prioritized and documented in a manner that facilities prioritizing outcomes and developing or modifying the plan...Outcomes are derived from actual or potential diagnoses and care issues, and shall be identified on the care plan by documentation of measurable goals within approximately 24 hours of admission to recognize and incorporate unique patient-centered values and care needs... The implemented plan and modifications are documented... Outcomes provide direction for continuity of care, and the plan establishes priorities for care.... Care is delivered in a manner that promotes patient safety...